[Congressional Record (Bound Edition), Volume 156 (2010), Part 3]
[House]
[Pages 4132-4462]
[From the U.S. Government Publishing Office, www.gpo.gov]




SENATE AMENDMENTS TO H.R. 3590, SERVICE MEMBERS HOME OWNERSHIP TAX ACT 
OF 2009, AND H.R. 4872, HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 
                                  2010

  The SPEAKER pro tempore. Pursuant to House Resolution 1203, it is now 
in order to debate the topics addressed by the Senate amendments 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, and 
the topics addressed by the bill (H.R. 4872) to provide for 
reconciliation pursuant to section 202 of the concurrent resolution on 
the budget for fiscal year 2010.
  The gentleman from Maryland (Mr. Hoyer) and the gentleman from Ohio 
(Mr. Boehner), or their designees, each will control 60 minutes.
  The Chair recognizes the gentleman from California (Mr. Waxman) for 
15 minutes as a designee of the majority leader.


                             General Leave

  Mr. WAXMAN. I would like to ask unanimous consent that all Members 
have 5 days in which to revise and extend their remarks and insert 
extraneous material in the Record.

[[Page 4133]]

  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.
  Mr. WAXMAN. Madam Speaker, I yield 1 minute to the majority leader of 
the House of Representatives, the gentleman from Maryland (Mr. Hoyer).
  Mr. HOYER. I thank my friend for yielding.
  Today is March 21, 2010. On March 21, 1965, Martin Luther King, Jr., 
led a march across the Edmund Pettus Bridge. It was a march across that 
bridge for the vote in this democracy. It was a march towards a greater 
freedom for many Americans. It was a march for a better quality of life 
for many Americans. Indeed, it was a march across the Edmund Pettus 
Bridge for freedom and a better realization of the promise of our 
democracy.
  Today, March 21, 2010, we will cross another bridge. It is not a 
physical bridge, but it is a bridge that too many Americans find that 
they cannot cross; a river that separates them from the security of 
having available the best health care that is available in the world 
available to them.
  We are here to conclude a day of debate, which concludes months of 
debate, in a national conversation that began more than a century ago.

                              {time}  1845

  But this much is beyond debate. American health care is on an 
unsustainable course. By the end of this debate, another family will 
have fallen into bankruptcy because someone had the bad fortune simply 
to be sick. More families will have joined them in paying more and more 
for less and less health coverage. More businesses will have weighted 
bankruptcy against cutting their workers' care and their workers will 
have lost.
  We have before us a bill to change an unsustainable course. That is 
our choice this evening. It is a historic choice. It's a choice that 
all of us volunteered to be put in the position to make. It is a choice 
that we will be honored to make this evening. We stood in this Chamber 
tonight with John Dingell, John Dingell, who stood at that rostrum with 
the gavel that the Speaker will use tonight to gavel through Medicare, 
that ensured that millions and millions and millions of seniors would 
not be crushed by poverty and put into bankruptcy by the cost of health 
care.
  Indeed, they will have been given the opportunity for a longer, 
better quality of life in America when John Dingell brought that gavel 
down on that desk and noted the passage of Medicare in 1965.
  For more than 3,000 district events, more than 100 hearings, and 
almost 2 years of public debate, health insurance reform has stood up 
to the scrutiny, to criticism, indeed, to falsehoods. But this purpose 
is older than that. Before we were born, the task of bringing 
affordable health care to every American was on our Nation's agenda, 
waiting for this day. At the beginning of this decade in 2002, George 
W. Bush said, ``All Americans should be able to choose a health care 
plan that meets their needs at affordable prices.'' George Bush was 
right.
  In 1976, Gerald Ford spoke of ``our effort to upgrade and perpetuate 
our total health care system so no individual in this country will lack 
help whenever or wherever he needs it.'' Gerald Ford was right.
  And Richard Nixon said this, ``Let us act now.'' That was in 1974, 
when there were far fewer Americans who did not have health insurance 
and where health care was less costly. Richard Nixon was right in 1974 
on this issue. Let us in 2010, in a bipartisan way, perhaps not a 
bipartisan vote, but recognizing that this has been a bipartisan 
objective, a bipartisan vision, for those Republican Presidents and 
Democratic Presidents whom I have not quoted but whom, as all of you 
know, were equally committed to that vision and that objective, 
affordable health care for all, for all Americans. It was embraced by 
both parties' nominees in the last campaign, Senator Obama and Senator 
McCain.
  But what a campaign of fear this bill has faced this last year. Its 
critics call it, without justification, and we will hear it tonight, a 
``government takeover.'' That's not true, but if you believe it's true, 
perhaps you think we ought to repeal veterans health care, which is 
clearly government-run health care. Perhaps we ought to repeal 
Medicare, government participated but private sector providers. Perhaps 
you believe Medicare should be repealed. I don't think you do; I hope 
you don't.
  It is more control, however, for whom? For consumers, and less for 
insurance companies. It is the end of discrimination against Americans 
with preexisting conditions, and the end of medical bankruptcy and caps 
on benefits. It is coverage you can rely on whether you lose your job 
or become your own boss, coverage that reaches 95 percent of all 
Americans. Its critics call it tyranny. There is none.
  It is a free, competitive, transparent marketplace where individuals 
and small businesses can pool together to buy private insurance at low 
rates. It is lower cost for the middle class and an end to the 
prescription drug doughnut hole that has faced too many struggling 
seniors. Its critics mock this as ``out-of-control government.''
  In truth, it is the biggest definite-reduction bill any of us will 
have an opportunity to vote on in this Congress and, indeed, in other 
Congresses as well. Indeed, it's the deepest definite reduction since 
the Clinton budget of the 1990s that ushered in a budget surplus and 
historic prosperity.
  According to the nonpartisan CBO, this bill is $143 billion in 
savings in the first decade and more than $1 trillion of savings in the 
second decade. We can add to those deficit savings real cost controls 
that bring down the price of the world's most expensive health care. 
Take those into account, says leading health care economist David 
Cutler, and America saves an additional $600 billion in the first 10 
years and even more in the second 10 years.
  Yet there are some who hope for the bill's defeat. They would see 
that, I think, as the defeat of one party. One Senator made that 
observation and said this might be the President's Waterloo. If this 
bill fails, the Waterloo will be that of the people who are without 
health care insurance, the people who are struggling to make sure that 
their children are healthy and well and safe. But it would be a defeat 
for them and for our country, for a healthy America is a stronger 
America.
  They saw the same thing in 1993, my Republican colleagues, when to a 
person, as I believe will happen tonight, unfortunately, in 1993, to a 
person they did the same thing. My Republican friends voted without a 
single exception against the 1993 economic reform plan of the Clinton 
administration.
  Congressman Boehner asked, ``Who does this spending stimulate except 
maybe the liberal faculty at Harvard or Berkeley?''
  Congressman Kasich said, ``If it was to work, then I'd have to become 
a Democrat. ``
  It did work, and he didn't change. It was a partisan vote, Mr. 
Speaker, a partisan vote that helped create 22.7 million new jobs, 
contrary to what so many of my Republican friends said that bill would 
do, and a record budget surplus of $5.6 trillion, contrary to the 
assertion of Mr. Armey that it would create deep debt.
  That bill passed through a gauntlet of slurs, hyperbole, and 
untruths, and so did Medicare, which Republicans called ``brazen 
socialism,'' and so did Social Security, which a Republican Congressman 
called the ``lash of the dictator.''
  I don't know whether there are any Republicans in this body tonight 
that believe that Social Security is the lash of the dictator. I hope 
not.
  Those slurs were false in 1935, they were false in 1965, and, ladies 
and gentlemen of this House, they are false in 2010. Ladies and 
gentlemen of this House, this bill, this bill will stand in the same 
company, for the misguided outrage of its opposition and for its 
lasting accomplishment of the American people.
  In closing, Mr. Speaker, I want to honor some of the ``little punk 
staffers'' who gave so much to help us bring this bill to the floor. I 
say to my friends on the other side of the aisle who did so much to 
bring your prescription drug bill to the floor, they

[[Page 4134]]

need to be honored. They need to be thanked. They need to be respected 
for the work they do for this House, for each of us but, more 
importantly, for America.
  From the Legislative Counsel's Office, Ed Grossman, Jessica Shapiro, 
Megan Renfrew, Warren Burke, Larry Johnston, Henry Christrup, Wade 
Ballou and Scott Probst.
  I also want to honor, Mr. Speaker, the tireless staffs of the House 
Committees on Ways and Means, Energy and Commerce, Education and Labor, 
Rules, and the Budget, as well as the staff of the CBO, Doug Elmendorf, 
Holly Harvey, Phil Ellis, Kate Massey, Pete Fontaine and the whole CBO 
health care team, along with Tom Barthold, and everyone of the staff on 
the Joint Committee on Taxation, who contributed to their estimates.
  Finally, two remarkable staffers in my office have made health reform 
the cause of their lives and just about every one of their waking hours 
for the past year, Liz Murray and Ed Lorenzen. Thank you very much.
  Mr. Speaker, one of my staffers, my deputy chief of staff, has a 4-
year-old daughter. She is a beautiful young girl, she is a smart young 
girl. Her name is Colette. A few days ago a neighbor asked Colette 
where her mom was, and I am told that she answered, She's at work 
making sure everyone can go see the doctor. Thanks, Mom. Thanks to all 
the moms throughout America who, when we pass this bill, will have a 
greater sense of security for their kids, for their families, for 
themselves.
  I know this bill is complicated, but it's also very simple. Illness 
and infirmity are universal, and we are stronger against them together 
than we are alone. Our bodies may fail us; our neighbors don't have to. 
In that shared strength is our Nation's strength, and in this bill is a 
prosperous and more just future.
  Unfortunately, much of this debate has been divisive, much of it has 
been irrelevant. We have seen angry people at the doorstep of the 
Capitol. Every President in this last century has said this is 
necessary for a great Nation to do.
  My colleagues, how proud we must all be that our neighbors have 
elected us to come here in this, the people's House, to do this good 
work this night.

                              {time}  1900

  The SPEAKER pro tempore. The gentleman from Texas (Mr. Barton) is 
recognized for 10 minutes as a designee of the minority leader.
  Mr. BARTON of Texas. Madam Speaker, I yield to the gentleman from 
Alabama for a unanimous consent request.
  Mr. ROGERS of Alabama. Madam Speaker, I rise in opposition to this 
flawed health care bill.
  Mr. BARTON of Texas. Madam Speaker, I yield to the gentleman from 
North Carolina for a unanimous consent request.
  Mr. COBLE. Madam Speaker, I rise in opposition to this flawed health 
care bill.
  Mr. Speaker, I rise in opposition to the proposed government takeover 
of our health care system.
  I have not come at this decision lightly. Although a small portion of 
my constituents support this proposal, the vast majority want nothing 
to do with it. Clearly there are areas of our health care system that 
need to be improved. That being said, this bill is a complete overhaul 
of the system.
  Make no mistake about it. This bill will put the government in 
control of our health care. It is a train wreck waiting to occur and 
considering our current economic morass, we need no train wrecks.
  It is with the best interests of all of my constituents, their 
children and future generations that I will oppose this legislation.
  Mr. BARTON of Texas. Madam Speaker, I yield to the gentleman from 
Minnesota for a unanimous consent request.
  Mr. PAULSEN. Madam Speaker, I rise in opposition to this flawed 
health care bill.
  Mr. Speaker, this body is nearing what will be a defining vote for 
the future of our nation.
  While Majority Leadership continued the arm twisting until enough 
members would vote for the bill, the voice of the American people got 
louder.
  They have made it clear they do not want this bill. My constituents, 
by a margin of over 3 to 1, have told me they don't like this plan--and 
with good reason.
  This bill will cost nearly 1 trillion dollars in the next decade 
alone--and the true cost of this bill will surely go higher as 
entitlement spending soars and other provisions are fully phased in.
  The bill is loaded with job-killing tax increases--and an Associated 
Press analysis said health care premiums will actually go up under this 
plan.
  The bill will also allow the IRS to verify if you have ``acceptable'' 
health care coverage and fine you if you don't!
  This bill will cut $500 billion from Medicare and in turn use that 
money for new entitlement spending. And history has shown entitlement 
spending goes up, not down, over time. With our current entitlement 
programs already headed for insolvency, why on earth would you 
exacerbate the problem?
  I would be remiss if I didn't mention that this legislation also 
negatively impacts our Nation's veterans. It betrays the promise that 
this county made to honor their sacrifice by failing to cover millions 
of beneficiaries including dependents, widows, survivors and orphans.
  The VFW has expressed their opposition to this bill and this body 
should not pass any bill that negatively impacts our veterans. Those 
families who have proudly served this country deserve better.
  Finally, the legislation contains a $20-billion tax on American 
medical manufacturers. This tax--which will hit manufacturers of 
technologies now common in modern medicine such as pacemakers, stents 
and MRI scanners--will be levied against many medical device 
manufacturers in my home state of Minnesota. In the end, this will harm 
jobs and cause patients to pay more for fewer medical technologies--the 
exact opposite of what we need.
  I believe this Nation needs real, bipartisan health care reform the 
American people can support. This bill should be set aside and replaced 
with common sense measures that will actually lower costs for everyone.
  Mr. BARTON of Texas. Madam Speaker, I yield to the gentleman from 
Georgia, the ranking member of the Health Subcommittee, Mr. Deal, for 1 
minute.
  Mr. DEAL of Georgia. I thank the gentleman for yielding.
  Madam Speaker, it has been said that the problem with socialism is 
that you eventually run out of other people's money.
  Despite billions of dollars in new taxes, despite billions of dollars 
in cuts to Medicare, and despite deceptive accounting practices to hide 
the true cost of this bill, it appears that we have run out of what 
money is here in Washington, because we are seeking to impose 
unprecedented and unconstitutional mandates on our States.
  Tonight, as I cast what might be the last votes of my congressional 
career, I am pleased to say that as I pursue my full-time activity to 
become the governor of the great State of Georgia, that I will cast my 
vote in opposition to this bill.
  If this bill becomes law and I am successful in my undertakings, I 
will devote my efforts to making sure that the people of my State are 
not subjected to the unconstitutional individual mandate and that my 
State is not subject to the unconstitutional mandate to expand our 
Medicaid rolls. I know that I am not alone. Yesterday, 38 States 
indicated that they would join in suing to challenge the 
constitutionality of this statute.
  I urge my colleagues to join me on a ``no'' vote.
  Mr. WAXMAN. Madam Speaker, I yield myself 2 minutes.
  Today is a historic moment. We will take decisive votes to provide 
quality affordable health care for all Americans. This is a goal that 
Presidents of both parties have sought for 100 years. We must act. The 
status quo is unsustainable.
  This bill provides all Americans the security of knowing they will 
always be able to afford health care for themselves and their families.
  The bedrock foundation of the legislation is that it builds on what 
works today and reforms what doesn't, but we fundamentally reform the 
insurance company practices that are failing our families.
  Americans with preexisting conditions can no longer be denied 
coverage. We abolish lifetime limits on coverage. And we ban the 
practice of rescission

[[Page 4135]]

by insurance companies when people get sick.
  We strengthen Medicare. Seniors who hit the donut hole for their drug 
coverage will get immediate help, a $250 rebate this year, a 50 percent 
discount on their brand name drugs next year, and the donut hole will 
be completely eliminated within the decade. We provide coverage to 32 
million uninsured Americans. We eliminate waste, fraud, and abuse. The 
American people will see immediate benefits.
  Today we vote to make a profound difference for the betterment of the 
American people. Under the leadership of the President and our Speaker, 
we are poised to provide access to quality health insurance for all.
  Today is a historic moment.
  We will take decisive votes to provide quality, affordable health 
care to all Americans.
  This is a goal that Presidents of both parties have sought for a 
hundred years.
  We must act. The status quo is unsustainable.
  This bill provides all Americans the security of knowing they will 
always be able to afford health care for themselves and their families.
  The bedrock foundation of this legislation is that it builds on what 
works today, and reforms what doesn't.
  If you like your doctor and your current plan, you keep them.
  But we fundamentally reform the insurance company practices that are 
failing our families:
  Americans with pre-existing conditions can no longer be denied 
coverage.
  We abolish lifetime limits on coverage.
  And your health coverage can no longer be rescinded by your insurance 
company if you get sick.
  We strengthen Medicare.
  Seniors who hit the donut hole will get some immediate help: a $250 
rebate this year, and a 50 percent discount on their brand-name drugs 
next year.
  And the donut hole will be completely eliminated within a decade.
  We provide coverage to 32 million uninsured Americans--not just those 
without insurance today but many who would otherwise be expected to 
lose their coverage in the coming years.
  We eliminate waste, fraud, and abuse and reduce the deficit by over a 
trillion dollars.
  And we eliminate the special deal for Nebraska, providing all states 
equitable treatment under Medicaid.
  The American people will see immediate benefits on enactment.
  Starting this year: Your children can stay on your policy through age 
26.
  Preventive care under Medicare is free.
  And children with pre-existing conditions cannot be denied coverage.
  Today we vote to make a profound difference for the better for the 
American people.
  Under the leadership of the President and our Speaker, we are poised 
to provide access to quality health insurance for all Americans.
  I now want to turn to some specific provisions in the Senate bill, 
H.R. 3950.


    Section 2304. Clarification of definition of medical assistance

  Section 2304 of H.R. 3590 as passed by the Senate clarifies the 
definition of medical assistance. This clarification is identical to 
that in section 1781(e) of H.R. 3962 as passed by the House and in 
section 1781(e) of H.R. 3200 as reported by the Committee on Energy and 
Commerce. The purpose of this clarification is set forth in H. Rept. 
111-299, Part 1, at pp. 649-650.


          Section 3301. Medicare coverage gap discount program

  I, on behalf of myself and Chairman Levin, express our intent 
regarding this section. Section 3301 of this legislation provides for 
50 percent discounts for brand name drugs in the Part D donut hole. It 
requires that manufacturers enter into an agreement to provide such 
discounts as a condition of participation in the Part D program.
  This section adds to the Social Security Act new Section 1860D-
43(c)(1), which provides a limited exemption from the requirement to 
provide a discount if the Secretary makes a determination that the 
availability of the drug is essential to the health of beneficiaries 
under this part. This intent of this exemption, if it is used at all, 
is that it be used only in extraordinary circumstances, and that it be 
of limited duration. For example, if a new drug manufacturer without an 
agreement already in place receives a new drug application approval 
after the period in which annual agreements are supposed to be signed 
by the Secretary, the Secretary could find that the drug is essential 
to beneficiaries' health and provide a short-term exemption until an 
agreement with the manufacturer is in place. Any exemptions provided 
under this section are intended to be temporary in nature.
  Moreover, nothing in this section requires the Secretary to make a 
finding that a given drug is essential to beneficiaries' health, or 
provides a right of action for any individual or organization to force 
the Secretary to make such a finding.
  This provision also contains civil monetary penalties for 
manufacturers that fail to provide applicable beneficiary discounts. 
The civil monetary penalties specified in this provision are not the 
sole penalties that can be applied to manufacturers that violate 
requirements of this section or other provisions of law. For example, 
relevant CMPs that apply to Medicare fraud or misleading statements and 
False Claims Act penalties can also be applied to manufacturers that 
fail to provide required discounts.
  Another provision of this section states that the Secretary ``shall 
not receive or distribute any funds of a manufacturer under this 
program''. This provision refers only to manufacturer funds, not to 
other funds or information. Section 1860D-43 contains no restriction on 
the ability of the Secretary, CMS, or the Inspector General to obtain 
(from any manufacturer, PDP or MA-PD plan, or other entity) any data or 
information necessary for the purposes of program compliance and 
integrity or audit purposes, or otherwise necessary to identify and 
eliminate waste, fraud, or abuse under this section.


           Section 3403. Independent Medicare Advisory Board

  I wish to clarify certain aspects of legislative intent regarding the 
Independent Payment Advisory Board (IPAB), which is a new executive 
branch body created in the Senate passed health reform bill and charged 
with constraining Medicare spending. Section 1899A(c)(2)(A)(iii) of the 
Social Security Act, as added by Section 3403 of PPACA, states that in 
the case of IPAB proposals submitted prior to December 31, 2018, IPAB 
shall not include any recommendations that would reduce payment rates 
for providers that receive an additional market basket cut on top of 
the productivity adjustment. The rationale for this provision is that 
these providers are already facing extra downward adjustments in their 
payments and thus should not be subject to ``double jeopardy'' by also 
being subject to IPAB recommendations which will further reduce 
spending. In creating this exclusion, it is the intent of Congress to 
exclude all payment reductions applicable to providers captured by this 
language in all the relevant years. Therefore, in the case of inpatient 
hospitals, the provision excludes from IPAB recommendations payment 
reductions applicable to hospitals including payment reductions for 
indirect medical education under 1886(d)(5)(B), graduate medical 
education under 1886(h), disproportionate share hospital payments under 
1886(d)(5)(F), and capital payments, as well as incentives for adoption 
and maintenance of meaningful use of certified electronic health record 
technology under 1886(n). As part of the effort to make improvements to 
the Senate-passed bill, Members of the House and Senate, along with the 
administration, were working on a number of improvements to the IPAB 
policy. Unfortunately, the Senate parliamentarian indicated that we 
could not modify IPAB in reconciliation. Since we were not able to make 
any changes to the IPAB as part of the reconciliation bill, I look 
forward to working on these improvements in the future.


                              Section 3512

  I have spoken with several Members, including Congressman Cuellar of 
Texas, that have expressed concerns about whether the language of these 
bills may be interpreted or construed as creating a new cause of action 
or claim or would modify or impair existing state medical malpractice 
laws.
  It is not and never has been the intent of this legislation to create 
any new causes of action or claims premised on the development of 
guidelines or other standards.
  Section 10201(j) of H.R. 3590, which was part of a manager's 
amendment adopted on the Senate floor and added Section 3512 to 
Subtitle F of title III of the Act, calls for the Comptroller General 
to conduct a study of whether the development, recognition or 
implementation of any guideline or other standards under a list of 
enumerated sections of the Senate bill would result in a new cause of 
action or claim.
  Any guideline or standard created under the above enumerated sections 
should not be construed as creating any such new actions or claims, nor 
should the request for a study be construed to infer otherwise. This 
legislation should not be interpreted or construed as creating any 
inference or implication that any such guideline or other standard does 
create any new cause of action or claim.
  It is also not and never has been the legislative intent of this 
legislation to modify, impair or supersede any State medical liability 
law governing legal standards or procedures used

[[Page 4136]]

in medical malpractice cases, and this legislation does not have the 
authority to prohibit the states from implementing such laws.


                  Section 6111. Civil Money Penalties

  The legislation we will pass today contains nursing home reforms that 
will make it easier to identify owners responsible for inadequate care, 
improve enforcement, and improve nursing home quality nationwide. These 
improvements represent a significant step forward. Nearly identical 
provisions were included in health care reform legislation that passed 
in the Energy and Commerce Committee, and in HR 3200 as passed by the 
House.
  Section 6111 of the legislation makes collection of civil monetary 
penalties more timely by allowing funds to be escrowed after an 
independent informal dispute resolution process until other appeals are 
concluded.
  A November 2009 GAO report found that understatement of deficiencies 
may result from ``unbalanced'' independent dispute resolution processes 
currently used. Over 40 percent of surveyors in four states told GAO 
that their states' independent dispute resolution processes favored 
nursing home operators over resident welfare.
  In order to avoid these problems, the intent of this section is that 
independent informal dispute resolution processes should be conducted 
by an independent state agency or entity with healthcare experience, or 
by the state survey agency, so long as no entity or individual who 
conducts independent informal dispute resolution has a conflict of 
interest. The Secretary's implementing regulations may address the type 
and duration of the independent informal dispute resolution processes. 
as determined by the Secretary. As under current law, facilities may 
challenge only the factual basis of the deficiency; and states and the 
Secretary retain the right to reject independent informal dispute 
resolution processes recommendations, any person shall have the right 
to attend and participate in the conference.
  I reserve the balance of my time.
  Mr. BARTON of Texas. Madam Speaker, I yield to the gentleman from 
Michigan (Mr. Upton) for 1 minute.
  Mr. UPTON. Madam Speaker, folks are scared. They are really scared. 
Debt is at a historic level, spending is out of control, the Nation's 
AAA credit rating is in jeopardy, and here we are.
  We are going to spend $1 trillion over the next 10 years for just 6 
years of benefits. Only in Washington can folks stand here and claim 
spending $1 trillion will actually cut the deficit.
  And how did we get here? Well, we are going to start by raiding $523 
billion from the Medicare checks of older Americans. Shameful.
  Whatever happened to tort reform? Not here. The lawyers are going to 
continue to get richer suing doctors and hospitals, and older Americans 
will see their benefits evaporate. Where are our priorities?
  Yesterday I introduced an amendment that would delay the bill until 
we can guarantee Medicare's solvency for at least the next 30 years, 
but it was denied. I guess they would rather spend money that we don't 
have rather than uphold our commitment to seniors. Debt continues to 
soar beyond belief. Today, every man and woman will spend $46,000 on 
the debt. Let's do better. We can.
  Mr. WAXMAN. Madam Speaker, I am proud at this time to yield 2 minutes 
to the gentleman from Michigan (Mr. Dingell), the distinguished dean of 
the House, who has championed the cause of health care in all of the 
time he has been in the Congress. And before that, his father called 
upon the Congress to adopt this legislation as well.
  Mr. DINGELL. Madam Speaker, I thank my colleague, Mr. Waxman, for his 
leadership and for his gracious comments. And I want to thank and 
praise our Speaker, our majority leader, and the leader in the Senate 
for the great leadership that they have given us in this great 
undertaking.
  Today is a day that is going to rank with the day we passed the civil 
rights bill in 1964. Today we are doing something that ranks with what 
we did on Social Security or Medicare. This is the day on which we can 
all be proud if we vote for that legislation.
  Facts are an intransigent hard thing. And let's look at this from the 
standpoint of the facts of what it does.
  Thirty-two more million Americans are going to have health care. They 
don't now. America, which has health care of the best character in the 
world, does not make it available to 32 million people because they 
can't afford it, and Americans every day are losing their health care. 
Eighteen thousand Americans every year die for want of health care, and 
44,000 Americans also go bankrupt because of it.
  What does this bill do? It gives Americans the same health care that 
we here in the Congress have. It preserves their choice, and it sees 
that if those Americans want to change, they can do so.
  It also fixes the insurance company. And as the President has said, 
this bill is the patient's bill of rights on steroids. And as my 
colleagues who worked on this bill when we passed it years ago will 
remember, that that is legislation which protects the rights of 
citizens and ratepayers.
  And the reason that the insurance companies are so up in arms about 
it, and they are the ones that are opposing this bill, is because it is 
going to take care of their patients and because it is going to take 
care of their customers.
  What is it going to do? No more preexisting conditions. And, they 
can't cancel your policy while you are on the gurney riding into the 
operating room because you are sick.
  I want to commend my colleagues for this.
  Madam Speaker, I have much humility, joy, and pride in supporting 
H.R. 3590 and H.R. 4872.
  Madam Speaker, all the arguments, for and against, have been made. 
There have been endless hours of debate in committees, on the floor of 
this House, and in meetings throughout the country.
  We have heard innumerable stories that inspire us to act, and 
unfortunately stories that have caused us to question whether the 
civility of our discourse has reached irreversible lows.
  As the historic vote draws near, I urge my colleagues to act on 
behalf of the American people.
  Let us this day stand boldly to do what is right for the health and 
well-being of the our constituents, what is essential for the viability 
of American business, and what is necessary for our government.
  Let us resolve to do what generations before us determined needed to 
done to address one of the greatest needs in the history of our people.
  When we do this, history will smile upon us. And generations to come 
will say on this day, this President and this Congress performed 
something worthy to be remembered.
  For the sake of the American people, and in honor of my late father, 
I support the legislation before us and urge my colleagues to do the 
same.
  Mr. BARTON of Texas. Madam Speaker, I yield for a unanimous consent 
request to a member of the committee from the Keystone State of 
Pennsylvania, Dr. Murphy.
  Mr. TIM MURPHY of Pennsylvania. Madam Speaker, I rise in opposition 
to this flawed health care bill.
  Mr. BARTON of Texas. Madam Speaker, I yield for 1 minute to the 
gentleman from Florida (Mr. Stearns).
  Mr. STEARNS. Madam Speaker, this incredibly expensive $1 trillion 
health care bill will hurt many individuals that currently have 
insurance. The bill will hurt veterans because it does not accept 
TRICARE as a qualified medical plan. It will hurt seniors by cutting 
Medicare advantage to fund these new government programs. Mr. Stupak, 
no lawyer, will argue that an Executive order is law. So the Senate 
bill starts us on a path of government-sanctioned abortion-on-demand 
paid for by taxpayers. The U.S. has a $1.5 trillion deficit, and now we 
are adding $1.2 trillion over 10 years.
  The President pledged no family making under $250,000 would face tax 
increases, yet there are 12 new tax increases violating that pledge, 
and 46 percent of families making less than $66,000 will be forced to 
pay the individual mandate.
  The bill will expand the IRS by 17,000 auditors to enforce these new 
taxes. It will hurt businesses, create health care rationing, and move 
the United States of America to further fiscal instability.
  Mr. WAXMAN. Madam Speaker, I am pleased to yield at this time to the 
chairman of the Health Subcommittee, who has played such an 
instrumental role in the legislation, the gentleman from New Jersey 
(Mr. Pallone) for 1 minute.
  Mr. PALLONE. Madam Speaker, I am amazed when I hear my colleagues on

[[Page 4137]]

the other side of the aisle. They seem to ignore the fact that our 
health care system is in crisis. Millions of Americans are going 
without health insurance. Rising health care costs are bankrupting so 
many American families.
  Now, Democrats today have proposed a bill that will lower health care 
costs, give almost all Americans quality health care coverage the same 
as Members of Congress--and I am going to repeat that--the same as 
Members of Congress, and put an end to insurance company abuses.
  When we pass this bill, 32 million more Americans are going to be 
able to see a doctor on a regular basis. America's seniors are going to 
be able to get more help to afford their prescription drugs, which will 
keep them healthy and out of the hospital.
  The bottom line is that Americans will be healthier, fewer people 
will get seriously ill and incur outrageous medical bills for hospital 
and nursing home care. And, healthier people save the government and 
the health care system significant money even beyond the CBO 
projections.
  Madam Speaker, passage of this bill will lead to a healthier and a 
stronger America, and I urge my colleagues to vote ``yes.''
  Mr. BARTON of Texas. Madam Speaker, I yield 1 minute to the gentleman 
from the bluegrass State of Kentucky (Mr. Whitfield).
  Mr. WHITFIELD. Yesterday I read an article by Speaker Pelosi in which 
she said the health care bill they proposed would strengthen Medicare, 
reduce deficits, and bring the predatory practices of health insurance 
companies under control.
  How can you strengthen Medicare when you take $500 billion out of it, 
out of nursing homes, out of hospitals, and out of Medicare advantage?
  How do you claim you reduce the deficit by $138 billion when you 
include the taxes for 10 years and the expenditures for only 6 years?
  And how do you say you are going to control the insurance companies, 
and act like you are throwing them in the briar patch, when in fact 
they support this bill? They went to the White House and helped write 
this bill. Why? Because this bill requires small businesses and 
individuals to buy health insurance, and, if not, they will be subject 
to civil penalties.
  Health reform may be necessary, but this bill is the wrong bill.
  Mr. WAXMAN. Madam Speaker, I yield 1 minute to the gentleman from 
Massachusetts (Mr. Markey), a very important member of our committee.
  Mr. MARKEY of Massachusetts. On health care, the Democratic party is 
the ``party of hope'' and the Republicans are the ``party of nope.''
  The Democratic health care bill lowers prescription drug costs for 
seniors, expands coverage to 32 million more Americans, reduces the 
deficit by $143 billion over the next 10 years, and gives middle class 
families tax credits to help pay for health coverage.
  What do the Republicans say to this plan? They say ``nope.'' Nope to 
lowering prescription drug prices, nope to expanding coverage, nope to 
health insurance tax breaks.
  GOP used to stand for Grand Old Party. Now, it stands for grandstand, 
oppose, and postpone. They grandstand with phony claims about 
nonexistent government takeovers, they oppose any real reform, and then 
they want to postpone fixing a broken health care system. GOP: 
Grandstand, oppose, and postpone.
  Today we have a choice between change and more of the same, between 
``hope'' and ``nope.'' Ted Kennedy is looking down and smiling today. 
Vote ``aye'' for John Dingell, for Ted Kennedy, and for all of those 
Americans that need health care in our country.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Member from Massachusetts should heed 
the gavel.

                              {time}  1915

  Mr. BARTON of Texas. Madam Speaker, I yield 1 minute to the gentleman 
from Arizona (Mr. Shadegg).
  Mr. SHADEGG. Madam Speaker, never before in the history of our Nation 
has such a massive change in policy been made on a purely partisan 
basis and in the face of such overwhelming opposition. Tragically, this 
bill will destroy freedom and do incredible damage to the very fabric 
of our society.
  This bill is a bailout for the insurance companies. They get the 
individual mandate that they wanted all along--a mandate that is un-
American and unconstitutional. Mark my words: The massive expansion of 
Medicaid in this bill will bankrupt our States. Premiums for average 
Americans will go up, taxes will go up, the deficit will go up, and the 
debt will go up. This bill is the epitome of Washington politicians 
telling the American people, We know better how to run your lives than 
you do.
  We owe the American people much better than this. We owe them real 
health care reform. We owe them the kind of reforms that will bring 
down their premiums. We owe them across-State-line purchases. We owe 
them health care pooling so that the sick and the ill and those with 
preexisting conditions can get their health care paid for.
  We owe America better than this.
  Mr. WAXMAN. Madam Speaker, I'm honored at this time to yield 1 minute 
to a senior member of our committee, the gentlewoman from California 
(Ms. Eshoo).
  Ms. ESHOO. Madam Speaker, I feel so privileged to be part of a 
Congress that is on the threshold of making history. Since Teddy 
Roosevelt and all Presidents forward, we have struggled in our country 
to provide something for our people that has eluded them. As the 
Catholic sisters said as they urged us to vote for this legislation, 
they called it ``life affirming.''
  I think the step that we take this evening will perfect the union in 
our country. Why? Because the human body holds the soul. And when we 
help to cure, when we help to heal, when we recognize the dignity of 
every single American, that they have first-class citizenship and that 
they should indeed have health care coverage.
  This is a landmark piece of legislation. I feel privileged that my 
constituents have sent me here to cast a vote for it, and I urge 
everyone to do so.
  Madam Speaker, I rise in support of the landmark comprehensive health 
care reform that is before us.
  For the first time in history, Congress will pass legislation to 
finally insure all Americans. This legislation will reduce the deficit 
by $143 billion over 10 years and $1.2 trillion over 20; eliminate 
discriminatory insurance practices, and open the insurance market to 
millions of Americans who have been priced out.
  More than a century has passed since Teddy Roosevelt first called for 
health care reform. Nineteen presidents later, we stand on the 
threshold of history as we prepare to vote on this historic 
legislation. The American people have been waiting for this. The 
American people deserve this, and the status quo is no longer 
affordable or acceptable.
  To those who say we can't afford health care reform in the current 
economy, I say we can't afford not to. We spend more on health care 
than any other country in the world and the costs are crippling to our 
economy. If we do nothing, in 2015 health care spending will jump by 34 
percent. By 2020, health care premiums will double and in 2010 alone, 
we're projected to spend more than $2.6 trillion on health care.
  A vote for this legislation is to stand on the right side of history. 
I feel privileged to serve in Congress and to participate in this 
historic effort. We stand on the shoulders of those who toiled for 
decades, including Senator Edward Kennedy, to bring us to this moment.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Members are reminded to please heed the 
gavel.
  Mr. BARTON of Texas. Madam Speaker, I yield 1 minute to the 
gentlewoman from California (Mrs. Bono Mack).
  Mrs. BONO MACK. Madam Speaker, I rise in very strong opposition to 
this flawed bill that imposes new taxes, increases costs to consumers, 
and adds to our already massive deficit. This bill and the outrageous 
abuse of process and all the backroom deals needed to secure passage is 
simply the wrong approach.
  My father was a teaching physician at USC-LA County Medical Center. 
He

[[Page 4138]]

would have been appalled that a massive new bureaucracy will now be 
making the health care decisions for his patients. In my district, 
thousands of seniors will lose their preferred Medicare Advantage 
coverage that serves them so well and has saved lives.
  This bill is little more than a shell game that shifts costs, picks 
winners and losers, and does nothing to achieve real reform. The 
American people have resoundingly rejected this dangerous approach. 
True reform should be accomplished with bipartisan cooperation, not 
strong-arm tactics. The only thing that is truly bipartisan tonight is 
opposition to this deeply flawed bill. We can and must do better. I 
urge my colleagues to join me in voting ``no.''
  Mr. WAXMAN. Madam Speaker, I yield for a unanimous consent request to 
the gentlelady from the Virgin Islands (Mrs. Christensen), who's played 
a very active role in this legislation.
  Ms. CHRISTENSEN. Madam Speaker, I rise in strong support of the 
Patient Protection and Affordable Care Act.
  Madam Speaker, this morning the Congressional Black Caucus attended 
church together at the Mount Zion Baptist Church in Arlington, VA.
  We left there blessed, inspired and claiming the victory we are about 
to have today for the American people.
  As our Chair Barbara Lee reminded us from the Book of Esther, we are 
all here, called to service, for ``for such a time as this.'' And we 
are called to do what is right and best for the American people and for 
our country! We must pass H.R. 4872.
  With the passage of H.R. 4872, The Patient Protection and Affordable 
Care Act, we begin to guarantee that health care will be a right to all 
and not a privilege for a few.
  It has been a long road getting here, not just this past year but the 
past hundred years and thanks is due to Chairman Emeritus John Dingell, 
Speaker Nancy Pelosi, Majority Leader Steny Hoyer, Majority Whip James 
Clyburn and Chairmen Rangel, Waxman, Miller and Larson for their 
steadfast leadership, and commitment to making healthcare accessible, 
affordable and secure for all Americans across this country.
  And we could not have arrived to this day without the leadership, 
commitment and determination of our President, Barack Obama.
  We would have all wished for the perfect bill many of us envisioned 
when we started on this path. This is not it, but without question this 
bill will vastly improve the dysfunctional system we now struggle to be 
well in, and lay the foundation for the further work needed to achieve 
those things that are still needed but could not be included today.
  I want to especially thank all of our Democratic leaders for ensuring 
that the people of the Territories were not left out and my Democratic 
colleagues--especially the Congressional Black Caucus and our TriCaucus 
partners for their support and encouragement.
  They are all--including Senate Leader Reid--to be thanked and 
applauded for answering our call for prevention, nondiscrimination, 
equity and diversity in the bill's provisions and for going beyond 
insurance reforms to include measures specifically to eliminate health 
disparities for African Americans, all people of color, the poor, those 
living in rural areas and the Territories and our LGBT community.
  This is not only a historic day for our country, it is a great day.
  Today we begin to end the ``shocking and inhumane'' injustice in 
healthcare that the Rev. Dr. Martin Luther King, Jr. spoke of. Today we 
continue the march to the full greatness that is our Nation's destiny!
  I am proud to have been given the opportunity by the people of the 
Virgin Islands and our House leadership to be a part of this process, 
and though I am not able to cast a vote on this landmark legislation I 
support it fully, proudly and unreservedly.
  When the vote is called, let's do it! The victory has already been 
claimed for us and for the people of the United States--all of us.
  To God be the glory!
  Mr. WAXMAN. Madam Speaker, I yield 1 minute to the gentleman who's 
played a very influential role in this legislation, the gentleman from 
Michigan (Mr. Stupak).
  Mr. STUPAK. I wish to engage the chairman in a colloquy, if I may.
  Throughout the debate in the House, Members on both sides of the 
abortion issue have maintained that current law should apply. Current 
law with respect to abortion services includes the Hyde amendment. The 
Hyde amendment and other similar statutes to it have been the law of 
the land on Federal funding of abortion since 1977 and apply to all 
other health care programs--including SCHIP, Medicare, Medicaid, Indian 
Health Service, Veterans Health Care, military health care programs, 
and the Federal Employees Health Benefits Program.
  The intent behind both this legislation and the Executive order the 
President will sign is to ensure that, as is provided for in the Hyde 
amendment, that health care reform will maintain a ban on the use of 
Federal funds for abortion services except in the instances of rape, 
incest, and endangerment of the life of the mother.
  Mr. WAXMAN. If the gentleman will yield to me, that is correct. I 
agree with the gentleman from Michigan that the intent behind both the 
legislation and the Executive order is to maintain a ban on Federal 
funds being used for abortion services, as is provided in the Hyde 
amendment.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. WAXMAN. I yield the gentleman 30 additional seconds.
  Mr. STUPAK. I thank the chairman.
  I'm seeking the chairman's commitment that our conversations on this 
issue, the abortion issue, will continue.
  Mr. WAXMAN. I know that this is an issue of great concern to the 
gentleman from Michigan and many other members of the Energy and 
Commerce Committee. You have my commitment to work with you and other 
Members in the future.


                         Parliamentary Inquiry

  Mr. BARTON of Texas. Madam Speaker, I have a parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state his inquiry.
  Mr. BARTON of Texas. It has been agreed to, I am told, by the 
Parliamentarian and others, that if I yield to Mr. Sensenbrenner 2 
minutes right now, it will come out of Leader Boehner's time.
  The SPEAKER pro tempore. The Chair has been so advised of the 
minority leader's designation of that time.
  Mr. BARTON of Texas. I yield 2 minutes to the gentleman from 
Wisconsin (Mr. Sensenbrenner).
  Mr. SENSENBRENNER. I have listened to this colloquy and, frankly, it 
doesn't state the law. The proposed Executive order, which I have a 
copy of, specifically states that nobody can enforce the Executive 
order in any court. So the Executive order is merely a piece of paper 
that certainly will not have any effect of law.
  Earlier today, the gentlewoman from Florida (Ms. Wasserman Schultz) 
was quoted on Fox News saying, Well, it can't be changed by Executive 
order because an Executive order can't change the law. She was right on 
in that respect. An Executive order can't change the law.
  But even on a policy question, President Obama, at a campaign rally 
when he was running for election, criticized the Bush administration's 
excessive use of Executive orders. Congress' job is to pass 
legislation. The President can veto it or sign it. Executive orders are 
not part of his power. The President also said, I'm not comfortable 
with doing something this significant through Executive orders, 
relating to trying terrorists in military commissions.
  Now, finally, it is basic law, as reiterated by the Supreme Court as 
late as 2006 in the case of Hamdan v. Rumsfeld, that an Executive order 
cannot trump or change existing law. The Executive order that is being 
talked about now is a piece of paper. It will have no force and no 
effect. If one is concerned about preventing the exchanges that are 
established under the Senate bill that we will be voting on in a few 
hours, then the only thing that one can do is vote against that Senate 
bill to preserve the Hyde amendment from being expanded to programs 
that are created under the Senate bill.
  I'm sorry, but the gentleman from Michigan and the gentleman from 
California have misstated the law. It is pretty clear. And even the 
President said it during the campaign, and the gentlewoman from Florida 
(Ms. Wasserman Schultz) said it on TV earlier today.
  Mr. WAXMAN. Madam Speaker, I yield 1 minute to an important member of 
our committee who's played a very

[[Page 4139]]

important role in this legislation, particularly as it relates to his 
State and other areas as well, the gentleman from New York (Mr. Engel).
  Mr. ENGEL. I thank the chairman for yielding to me.
  Madam Speaker, I'm proud to be a Member of Congress, but never as 
proud as I am tonight. Tonight we're finally going to pass 
comprehensive health care for the American people.
  My friends on the Republican side of the aisle keep saying the bill 
is flawed. The only flaw was when they controlled Congress and had the 
President of the United States, not once did they try pass health care, 
not even incrementally, as they say we should do now.
  No longer, when we get sick, will the insurance companies say, Sorry, 
we can't cover you. No longer, if you lose your job or change your job, 
can you not keep your health insurance. You will be able to keep it. If 
have you a preexisting condition, you won't be able to be denied it. If 
you're 26 years old, you can stay on your parents' policies. There's no 
annual cap or lifetime cap. We help seniors by closing the doughnut 
hole in Medicaid. We save money. It's CBO scored.
  Everybody wins with this bill, but especially the American people. 
I'm proud that we're passing comprehensive health care. The current 
system is not sustainable financially, and what we're doing means that 
everybody wins.
  Mr. BARTON of Texas. Madam Speaker, I would yield 30 seconds to the 
gentleman from Oklahoma (Mr. Sullivan).
  Mr. SULLIVAN. I'd like to thank Congressman Barton for yielding me 
time.
  Higher premiums, higher taxes, and cutting Medicare is not health 
care reform. Republicans care about health care, but we don't care for 
this bill. Unfortunately, the White House and congressional Democrats 
are still insisting on their massive 2,700-page bill that includes 
higher premiums, $500 billion in higher taxes, and $500 billion in cuts 
to senior Medicare.
  My son, who's here this week, Tommy Sullivan, even can consider that 
that's not reform.
  Mr. WAXMAN. Madam Speaker, I'm pleased to yield, at this time, 1 
minute to someone who's been a very active member of the Health 
Subcommittee and the vice chairman of the full committee, the 
gentlewoman from Colorado (Ms. DeGette).
  Ms. DeGETTE. Madam Speaker, when you build a house, you have to first 
put down a foundation. Today, we are laying a foundation for a health 
care system that will provide every American with access to high 
quality health care; a foundation that will immediately ban insurance 
companies from dropping people from coverage when they get sick, people 
like my childhood friend who lost his insurance when he got prostate 
cancer and later died too young; a foundation that will, beginning this 
year, give tax credits to small businesses so they can offer affordable 
coverage to their employees; a foundation that will now give parents of 
young adults the ability to keep their kids on their policies while 
they start their careers; a foundation that will finally give adults 
with preexisting conditions the ability to buy affordable insurance. 
And starting right away, insurance companies cannot exclude children, 
like my own young daughter, Francesca, who have chronic conditions such 
as diabetes or asthma, from coverage.
  Madam Speaker, this bill is just a foundation. We need to build on 
it, but it's a strong foundation.
  Mr. BARTON of Texas. I'd like to yield 1 minute to one of our best 
pro-life leaders in the House of Representatives, the gentleman from 
Pennsylvania (Mr. Pitts).
  Mr. PITTS. This bill violates the conscience of the American people. 
It violates the principle that we should not spend more than we have. 
This bill is not reform. It just makes our existing entitlement crisis 
even worse. This bill violates the belief held by more than 70 percent 
of Americans that money collected by the government should not be used 
to pay for abortion or abortion coverage, but that's what this bill 
does.
  Regardless of the colloquy, an Executive order is not a statute. It 
doesn't trump a statute. The government will end up directly paying for 
abortions at community health centers. Taxpayer subsidies will, for the 
first time in decades, subsidize insurance coverage that includes 
abortion. The bill and the accompanying Executive order turns over the 
protection of the unborn to the most pro-abortion President in our 
history.
  This extreme legislation is being forced on an unwilling Nation. It 
is the most pro-abortion bill and the largest expansion of abortion in 
our history. No Member who votes for it will ever be able to claim 
again that they have always stood on the side of the unborn. I'm sad to 
say this. This is a career-defining vote. There will be no living it 
down.
  I urge my colleagues to vote ``no'' on this terrible bill.

                              {time}  1930

  Mr. WAXMAN. I yield 1 minute to my colleague from California (Mrs. 
Capps), who is a very active and influential member of the Health 
Subcommittee.
  Mrs. CAPPS. I thank the chairman. Madam Speaker, we've been trying to 
reform health care in this country for decades, and I've been blessed 
to participate both as a health care provider and now as a Member of 
Congress. Passing this bill is not only the right thing to do; it is 
truly a matter of life and death for the millions of Americans who 
today lack health insurance coverage, and it is critical for all who 
suffer from diseases that could have been completely preventible or 
dealt with earlier had they had access to screenings.
  One thing, our bill will now guarantee no more copays for preventive 
screenings for diseases like cervical cancer or heart disease. As a 
public health nurse with decades of experience, I know this is one of 
the most important steps we can take to improve the health of American 
families, and I stress this point because it's one that's not brought 
up all that often.
  I underscore the importance of universal access to preventive care 
because this measure will improve the lives of millions of families and 
save us all billions in avoidable health care costs. I know my 
constituents are going to appreciate these important provisions which 
will improve health care in the United States. It's one of the many 
reasons I urge my colleagues to vote ``yes'' on this bill.
  Mr. BARTON of Texas. Can I inquire as to the time remaining on each 
side for the Energy and Commerce Committee's control.
  The SPEAKER pro tempore. The gentleman from Texas controls 2\1/2\ 
minutes, and the gentleman from California controls 3 minutes.
  Mr. BARTON of Texas. I yield 45 seconds to the gentleman from 
Nebraska, the Cornhusker State, Mr. Terry.
  Mr. TERRY. We all want all people to have access to affordable health 
care, but this trillion-dollar tragedy is just bad medicine. Medical 
costs are high, but this bill does absolutely nothing to help reduce 
costs. It does take $500 billion from Medicare, resulting in cuts in 
service to seniors. It does raise taxes on many small businesses, 
including new mandates on businesses and actually increases premiums as 
much as 13 percent.
  In committee, I introduced an amendment that gives people access to 
exactly the same care that we have as Members of Congress, but Mr. 
Markey and almost all the Democrats voted against it. All Republicans 
voted for that. Last, the clear language of this bill allows abortion, 
and I encourage all Members to vote against it.
  Madam Speaker, I rise today in opposition to this unprecedented 
legislation that will affect one-sixth of our economy, saddle our 
children and grandchildren with trillions of dollars of debt, and lead 
to a government takeover of America's health care system.
  As a member of one of the House Committees with jurisdiction over 
health care, I have had a front row seat to watch a legislative process 
that has had one over-riding theme--no reform idea, bill, or amendment 
on health offered by a Republican or even a moderate Democrat was given 
any consideration. From

[[Page 4140]]

the start this has been a process that is best described as, ``our way 
or the highway.''
  This bill will result in rising health care costs and premiums. The 
Congressional Budget Office, CBO, reported in December that if the 
Senate bill was passed, average premiums per policy would rise by 10 to 
13 percent in 2016, resulting in annual premiums of $5,500 for single 
policies and $13,100 for families.
  According to the Congressional Budget Office, CBO, the health care 
bill carries a price tag of $940 billion over 10 years. Most revenue 
raisers come from new taxes on small business, individuals, and medical 
goods. Furthermore, the health care bill includes significant payment 
changes for Medicare Advantage and $500 billion in cuts to both 
Medicare and Medicaid. A number of arbitrary cuts are made to skilled 
nursing facilities, hospice, home health, Medicaid DSH payments, and 
popular Medicare Advantage plans. Specifically, the bill reduces 
Medicare Advantage payment benchmarks over the next 7 years, resulting 
in reduced access for millions of beneficiaries currently on Medicare 
Advantage plans. The ``savings'' Democrats purport are truly cuts to 
services that our seniors need. I don't think we can afford this plan 
and it will, in time, hurt both our economy and beneficiaries.
  The scoring used by CBO and our Democrat colleagues can best be 
described as ``new math.'' For example, a 10-year fix for Medicare 
reimbursement to physicians will cost $208 billion, yet that is not 
counted in the CBO score. But a separate deal has been struck with the 
doctors to do that later this year. So by my math, the real cost of 
health care reform is closer to $1.3 trillion, not $940 billion.
  A recent New York Times article highlighted a growing trend of 
physicians dropping Medicaid patients because of low payments--and the 
Democrats' solution to our health care crisis is to expand Medicaid 
eligibility to an additional 16 million more individuals over the next 
10 years? In a letter to Congress following the Health Care Summit, 
President Obama acknowledged the need to increase Medicaid 
reimbursement to ensure future services and yet, those anticipated 
additional costs are nowhere to be found in either H.R. 3590 or H.R. 
4872.
  Another ``new math'' trick being used by the Democrats is to tell the 
American people that the Medicare Part D drug benefit ``donut hole'' 
will be closed. Yes, the ``donut hole'' is partially closed by this 
legislation, but not closed entirely until the year 2020 which is after 
the scoring period used by the CBO. Again, this ``new math'' is being 
used as a gimmick to make it appear that this bill will reduce the 
deficit. But it will not. This bill costs more than Democrats claim.
  Last year, one of my Democratic colleagues stated, ``The fact of the 
matter is that some in the Republican party don't want these problems 
fixed because they're already doing just fine. They've got choice, 
they've got the federal plan, that's what I have. Well in the 
Democratic party we're saying something else, we want the American 
people to get at least as good as my friends in the Republican party 
have. We want at least the benefits that we have here in Congress--
choice, affordability, lower cost and lower taxes for all Americans.'' 
I wholeheartedly agree with Congressman Weiner that Americans should 
have access to the same plans as their Members. Last year I offered two 
amendments to Speaker Pelosi's bill. The first was my alternative plan 
called Simple Universal Healthcare, SUH, which creates a new health 
insurance program similar to the Federal Employee Health Benefits Plan 
now available to the President, Vice President, Members of Congress and 
all federal government employees. The plan allows the uninsured and 
small businesses access to more affordable insurance with options, 
portability and no mandates. The other amendment I offered would 
require that the President, Vice President, and Members of Congress 
enroll in Pelosi's public plan. Both amendments were prevented from a 
floor vote by Speaker Pelosi's rules.
  Yesterday, I attempted to offer the Simple Universal Healthcare plan 
as an amendment in the Rules Committee, however Speaker Pelosi ordered 
the nine Democrats on the Committee to kill all Republican amendments 
and therefore my bill did not survive.
  Madam Speaker, there are some in this chamber who may consider this a 
momentous day. And that it will be if the House of Representatives 
votes to spend trillions of dollars and forwards the bill to future 
generations. While we ramp up spending, we have not dealt with the 
exploding costs of Social Security, Medicare or Medicaid. We are on a 
path of fiscal recklessness that threatens the future economic growth 
of America. So for me, this is a sad day, one that could have been 
avoided had the House worked together on a bipartisan basis to provide 
the American people greater access to health care that we can afford.
  I urge my colleagues to vote ``no.''
  Mr. WAXMAN. Madam Speaker, I am pleased to yield 1 minute to the 
gentleman from Pennsylvania (Mr. Doyle), who has played a very 
significant role in bringing us all together and I think has a great 
deal of responsibility for getting this bill to the point where it is 
today.
  Mr. DOYLE. Madam Speaker, my office got a call today from Mary Anne 
Ferguson, 91 years old from Point Breeze in Pittsburgh. She asked me to 
vote for health reform because she wants everyone to get the coverage 
she has. She remembers before Medicare when half of our seniors worried 
about getting sick because they had no health insurance.
  Today, millions of working Americans fear getting sick because they 
don't have health coverage. One of those was Bill Koehler from Garfield 
in Pittsburgh. His sister Kitty says that Bill was a loving and 
generous man to his friends, family, and those in need. When he lost 
his job, he lost his coverage. His new job as a pizza delivery driver 
earned too much to qualify for Medicaid, and private insurance wasn't 
going to cover his preexisting heart condition--the very reason why he 
needed health insurance. He died last year from a heart attack while 
driving home.
  So when I'm called to vote tonight, I will stand on the side of Mary 
Anne Ferguson and Bill Koehler and the tens of millions of Americans 
who need us to pass this bill. ``Yes'' to health reform. ``Yes'' to 
Bill Koehler.
  Mr. BARTON of Texas. I would like to yield for a unanimous consent 
request to Mr. Rogers of Kentucky.
  Mr. ROGERS of Kentucky. Madam Speaker, I rise in opposition to this 
flawed health bill.
  Mr. BARTON of Texas. Madam Speaker, I would like to yield for a 
unanimous consent request to the gentlewoman from Tennessee (Mrs. 
Blackburn), a member of the committee.
  Mrs. BLACKBURN. Madam Speaker, I rise in opposition to this flawed 
bill.
  Madam Speaker, I have followed this debate closely. We all have. But 
I haven't heard a colleague from Massachusetts say, ``In spite of my 
State's five billion dollar budget deficit, CommonwealthCare is a great 
model.'' I haven't heard my colleagues from Maine say ``Dirigo covered 
more people and lowered costs, let's try that approach.'' My colleagues 
form New Jersey can't say, ``When we passed guaranteed issue laws, 
costs came down, let's try our model.'' And you certainly haven't heard 
any of the Tennessee delegation come to the floor and say, ``TennCare 
was a great success, let's try that!''
  You haven't heard these things because my colleagues know what is 
proposed today has been tried and tried and tried before. It has never 
worked. The theory sounds good, but the hard facts are that when you 
gamble that near-term costs will be made up by long-term savings, you 
always lose.
  The real losers will be our children and grandchildren who will labor 
under heavy taxes to finance their own mediocre care. There is a 
bipartisan collection of Members who know that is the only result of 
this bill. I hope that we will be a bipartisan majority.
  Mr. BARTON of Texas. Madam Speaker, I would like to yield for a 
unanimous consent request to the gentleman from the Peach State of 
Georgia, Dr. Gingrey.
  Mr. GINGREY of Georgia. Madam Speaker, I rise in the strongest 
opposition to this flawed health care bill.
  The SPEAKER pro tempore. The gentleman will be charged.
  Mr. BARTON of Texas. Madam Speaker, I would like to yield for a 
unanimous consent request to the gentleman from the Pelican State, Mr. 
Scalise, another member of the committee.
  Mr. SCALISE. Madam Speaker, I rise against this health care bill.
  Mr. BARTON of Texas. And, finally, Madam Speaker, I yield 45 seconds 
to another member of the committee, the distinguished Mr. Mike Rogers 
from the great State of Michigan.
  Mr. ROGERS of Michigan. Madam Speaker, if this bill is so great, why 
the deception? The lying, the stealing, the cheating? I have never seen 
such behavior in my entire time in politics. ``If you like your health 
care, you can

[[Page 4141]]

keep it.'' Not true, if you read the bill. Ten years of taxes, 6 years 
of services, if you read the bill. They steal money from the Social 
Security trust fund and cut $500 billion from Medicare.
  And not only that, Madam Speaker, but this pits one American against 
another in the cost of health care for the first time in our history. 
If you're a Florida senior citizen, you get to keep your Medicare 
Advantage. If you're from the other 49 States, you do not. And there is 
dirty deal after dirty deal after dirty deal in the bill that this 
House will vote on. It is a disgrace. It's wrong. America deserves 
better.
  Mr. WAXMAN. Madam Speaker, I yield 1 minute to the gentlewoman from 
Illinois, Jan Schakowsky, a member of our committee and the Health 
Subcommittee.
  Ms. SCHAKOWSKY. Tonight I want to express my profound thanks to the 
people of Illinois' Ninth Congressional District, the place where I was 
born and lived nearly all my life, for the privilege of being here 
tonight to cast my vote for this historic health care measure. My 
life's work has been to answer what is at bottom a moral question: Will 
the United States of America continue to allow our people to lose their 
lives, their homes and their fundamental sense of security, or finally 
decide that a proud and wealthy country like ours has an ethical 
obligation to provide access to health care for everybody? Is it even 
credible to think that a country as rich as ours in so many ways can't 
afford to do this?
  I am so proud that today this House, under the leadership of perhaps 
the most effective Speaker in U.S. history, Nancy Pelosi, will say to 
all those parents agonizing over a sick child who is now excluded from 
insurance coverage because of a preexisting condition, Sleep well. Our 
courageous and visionary President Barack Obama, when he signs this 
law, that problem will end. This is a great day for America.
  The SPEAKER pro tempore. The time of the gentlewoman has expired.
  The gentlewoman from Illinois is reminded to please heed the gavel.
  Mr. BARTON of Texas. How much time do I have remaining, please, Madam 
Speaker?
  The SPEAKER pro tempore. The gentleman has 55 seconds remaining.
  Mr. BARTON of Texas. I am going to yield to the gentleman from Texas, 
Dr. Burgess, 15 of those precious 55 seconds.
  Mr. BURGESS. I thank the gentleman for yielding. You know, it's 
really a shame we have this health care bill in front of us. We have 
provisions now for 17,000 new IRS agents but not one dollar for a new 
nurse or a new doctor. You know what, you'll have access, all right, 
but you may be getting your prenatal care from Turbo Tax.


                announcement by the speaker pro tempore

  The SPEAKER pro tempore. The Chair will remind all persons in the 
gallery that they are here as guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. WAXMAN. Madam Speaker, for the purpose of a unanimous consent 
request, I yield to the gentleman from the State of Washington (Mr. 
Inslee), a member of our committee.
  Mr. INSLEE. Madam Speaker, I rise in strong support for this American 
health care bill.
  The SPEAKER pro tempore. The gentleman will be charged.
  Mr. WAXMAN. Madam Speaker, for the purpose of a unanimous consent 
request, I yield to the gentleman from Texas (Mr. Edwards).
  Mr. EDWARDS of Texas. Madam Speaker, I rise in opposition to this 
bill.
  Madam Speaker, Americans need and deserve health care reform. Without 
it, the quality of our health care system will go down and costs will 
continue to go up. The present trend of fast rising health care costs 
and increasing numbers of uninsured is unsustainable. If left 
unchecked, these problems will bankrupt more businesses, hard-working 
families, hospitals, and, ultimately, state and federal budgets.
  This is why I had wanted to vote for health care reform, and this 
bill has a number of positive provisions in it that I support, such as 
providing tax cuts for small employers offering health insurance, 
creating a private health insurance exchange, helping seniors with 
their prescription drug costs and preventing discrimination against 
people with pre-existing conditions.
  However, I cannot vote for this bill, because at a time of 
unprecedented federal deficits, we simply cannot afford all of its new 
spending. I believe it would have been better to have passed a less 
expensive bill and less expansive bill, one that could have united, not 
divided, our Nation. In the long run, for health care reform to work, 
it must have the support and confidence of the American people.
  I realize it is easier to criticize than to write comprehensive 
health care reform legislation. I also realize that some of the 
criticisms lobbed at this bill are without merit, such as the false 
suggestion that it contains death panels. Nevertheless, I believe we 
could have passed a less complicated, more affordable bill this year 
that would have garnered widespread support across our country.
  Over the past year I have listened to thousands of constituents from 
all walks of life across our district on the issue of health care 
reform. What I have heard is that people generally like the quality of 
their present health care and don't want big government or big 
insurance companies to stand between them and their doctors. They also 
believe we must do something to make health care more affordable for 
families and businesses. I agree.
  Above all else, what I heard from my constituents is that they have 
to tighten their belts in this difficult economy, and they want the 
federal government to do a far better job of living within its means. 
There is great wisdom in that observation, and I believe we have a 
moral obligation to not drown our children and our economic future in a 
sea of national debt.
  Unlike the Medicare prescription drug bill that was passed in 2003 
without being paid for, I support the principle that health care reform 
should be paid for. I hope the Congressional Budget Office is right 
when it says this bill will reduce the deficit, but, frankly, I am 
skeptical that anyone can predict with absolute certainty the cost of 
such a complex, far-reaching bill over a period of 10 to 20 years.
  That is why I had urged that this bill include a fiscally responsible 
trigger mechanism in it that would cut spending if actual costs exceed 
projections, if cost savings are not fully realized or if projected new 
revenues are overestimated. The President mentioned such a trigger in 
his address to Congress last year, and a trigger was included in some 
parts of the bill. However, I am disappointed that my common sense 
proposal for a trigger covering all of the bill's costs and revenues 
was not included. Today, most Americans simply do not believe this bill 
will reduce the deficit and health care costs. I hope they are wrong, 
but I fear that they are right.
  A less expensive bill, with a fiscally responsible trigger in it, 
would have also reduced the need for the additional taxes and Medicare 
reductions included in this bill. Once the new revenues and Medicare 
savings have been used to pay for the new spending in this bill, it 
will be that much harder to find ways to reduce the massive federal 
deficits our Nation is facing for the foreseeable future.
  If left unchecked I believe huge federal deficits will harm our 
economic growth and our children's future. Increasing interest payments 
on our $12.7 trillion national debt will lead to higher taxes and crowd 
out vital education, health care, infrastructure, national defense and 
job training programs that are so important for hard-working families 
and our country.
  Reining in massive federal deficits will require tough choices, the 
same kind of choices families and businesses have to make every day. 
Given this year's deficit will be approximately 1.3 trillion dollars, I 
simply believe we cannot afford all of the new spending in this bill.
  If this bill becomes law, my hope is that Congress will protect its 
positive provisions but reduce its scope and costs to get our country 
back on track toward a balanced budget that can ensure economic 
opportunity for future generations of Americans.
  The SPEAKER pro tempore. The gentleman has 55 seconds remaining.
  Mr. WAXMAN. Madam Speaker, I yield the balance of my time to the 
gentlewoman from Wisconsin (Ms. Baldwin).
  Ms. BALDWIN. Madam Speaker, what this all boils down to is, Whose 
side are you on? Madam Speaker, I rise today on behalf of the 13,500 
people in my district who will finally have access to health insurance 
because of this measure. I rise for the 1,000 families in south central 
Wisconsin who will be protected from medical bankruptcy this year 
because of this effort. And I rise today because of the 539,000 
constituents who will see their coverage improve because of the work 
we've done.

[[Page 4142]]

  Madam Speaker, I rise with pride and hope in the promise of this 
health care reform bill. There is no doubt that powerful interests have 
strenuously opposed reform, and they've often resorted to tactics that 
could make no one proud. But nothing can sully the pride I feel today 
in taking this critical step to provide health coverage for all 
Americans. I've worked my entire career to achieve health care for all. 
Today we stand on the floor of the people's House ready to pass the 
bill.
  The SPEAKER pro tempore. The gentleman from Texas has 40 seconds 
remaining.
  Mr. BARTON of Texas. I yield myself the balance of my time.
  Madam Speaker, this bill will not last. It is based on a fatal 
assumption that one party acting unilaterally can dictate the entire 
will of the American people on one-sixth of the economy. That will not 
happen. It reignites the abortion debate. It is fatally flawed in its 
assumptions in terms of balancing the budget and deficit reduction, and 
it will take away coverage from millions of people if it gets as far as 
2014 and you kick in the option that puts all these mandates on 
employers.
  Please vote ``no.'' Let's go back, start over. Let's start from 
scratch and do a bill that everybody can support. Vote ``no'' on this 
bill.
  The SPEAKER pro tempore. The gentleman from Michigan (Mr. Levin) is 
recognized for 15 minutes as a designee of the majority leader.
  Mr. LEVIN. Madam Speaker, I yield myself 1 minute.
  We come to the floor for thousands of votes each year, but no single 
vote comes with so many personal stories within our families and my 
own. In our districts, people have spoken out about the need for real 
reform.
  The millions and millions that have health insurance now worry about 
losing it. The average premium for employer-based insurance has more 
than doubled in the last 10 years. And I heard from a woman that had 
worked for a large company, started her own franchise, and she writes, 
``I exhausted my COBRA, then joined a group health plan. Several years 
ago, I had open heart surgery. The group disbanded. No insurance 
company would touch me with a 10-foot pole. I am uninsured and was just 
diagnosed with my second episode of breast cancer, with no insurance.''
  I heard from a young man diagnosed with leukemia at the age of 17. 
His disease went into remission. He started to work. He was laid off, 
uninsured, and when he started to get sick again, he had to turn to 
emergency rooms for care.
  The SPEAKER pro tempore. The time of the gentleman from Michigan has 
expired.
  Mr. LEVIN. I yield myself 15 additional seconds.

                              {time}  1945

  Republicans have turned their back on the problems. Some of them have 
taken to saying health care reform makes us a different Nation; quite 
the opposite. Today, in the tradition of America, we will pass health 
care reform, and it will make our beloved America a still better 
Nation.
  The SPEAKER pro tempore. The gentleman from Michigan (Mr. Camp) is 
recognized for 10 minutes as a designee of the minority leader.
  Mr. CAMP. Madam Speaker, I yield myself 1 minute.
  The American people have spoken. They do not want the tentacles of 
the Federal Government reaching into their lives and controlling their 
personal health care decisions. Yet that is exactly what will happen 
under the Democrats' health care bill. Federal bureaucrats will be 
making your health care choices for you and your family, and the IRS 
will be enforcing them.
  The American people know that you can't reduce health care costs by 
spending a trillion dollars or raising taxes by more than half a 
trillion dollars. The American people know that you cannot cut Medicare 
by over half a trillion dollars without hurting seniors. And the 
American people know that you can't create an entirely new government 
entitlement program without exploding the deficit. They are right, and 
the nonpartisan Congressional Budget Office has confirmed it.
  Simply put, the Democrats' bill will not only ruin our health care 
system, but the tax increases will ruin our economy and kill jobs.
  I urge my colleagues to listen to the American people and kill the 
bill.
  I reserve the balance of my time.
  Mr. LEVIN. Madam Speaker, it is now my real privilege to yield 1 
minute to the distinguished gentleman from New York (Mr. Rangel) who 
has given decades and decades of service to this Congress, to New York, 
and to the people of America.
  Mr. RANGEL. Thank you, Mr. Chairman.
  Madam Speaker, my colleagues, one of the lowest points in my 
political career was when I asked for a leave of absence from the 
chairmanship of the Ways and Means Committee. I had thought at that 
time with my feeling about how important it would be for the entire 
Nation to have access to quality health care that I did not want to do 
anything or be anywhere to distract from our leadership, Nancy Pelosi, 
our leader Steny Hoyer or Jim Clyburn, but most important, the great 
Members who worked so hard with me and our dedicated staff to get out 
the first bill on this very important subject.
  When people ask how do you feel and how are you today, I can report 
that this has been one of the most historic moments of my life, to be 
privileged to serve in this great body and to be a part of this 
legislation that I know that, no matter how long anybody has been in 
this great legislative body, people will ask, Which side have you been 
on? And thank God I am on the right side.
  Mr. CAMP. Madam Speaker, I yield 45 seconds to the gentleman from 
California (Mr. Herger), a distinguished member of the Ways and Means 
Committee.
  Mr. HERGER. Madam Speaker, the American people have spoken again and 
again. They do not want to spend nearly $1 trillion on a new government 
health care program paid for by raising taxes, and raiding the Medicare 
trust fund. They don't want to force everyone to buy government-
approved health insurance or subsidize health plans that cover 
abortion. And they don't want a 2,400-page bill riddled with backroom 
deals.
  Madam Speaker, Americans are watching and know what is at stake. 
Let's reject this destructive legislation.
  Mr. LEVIN. Madam Speaker, in terms of seniority and in recognition of 
all of his years of service, I would like to note that the gentleman 
from California (Mr. Stark) is going to be submitting a statement to 
the Record. And I am now pleased, it is a special privilege, to yield 1 
minute to the very distinguished gentleman from Georgia, Mr. John 
Lewis.
  Mr. LEWIS of Georgia. Madam Speaker, this may be the most important 
vote that we cast as members of this body. We have a moral obligation 
today, tonight to make health care a right and not a privilege.
  There are those who have told us to start over. There are those who 
have told us to wait. They have told us to be patient. We cannot wait. 
We cannot be patient. The American people need health care, and they 
need it now. On this day at this hour, stand with the American people 
and not with the big insurance companies. On this day at this moment in 
this Chamber, answer the call of history, answer the spirit of history 
and pass health care. Give the American people a victory. Give health 
care a chance.
  Mr. CAMP. Madam Speaker, I yield 45 seconds to a true American hero, 
the distinguished member of the Ways and Means Committee, the gentleman 
from Texas (Mr. Sam Johnson).
  Mr. SAM JOHNSON of Texas. Madam Speaker, today's vote defines what 
kind of America we want to live in. I for one know exactly what that 
is; it is the America I fought and sacrificed for, and all the freedoms 
we hold dear. Freedom from a $2.6 trillion Washington takeover of 
health care; freedom from skyrocketing taxes; freedom from bureaucrats 
coming between you

[[Page 4143]]

and your doctor; freedom from Medicare cuts to seniors; freedom from 
exploding debt; freedom from the government forcing you to buy health 
insurance.
  I ask my colleagues, what kind of legacy do you want to leave for 
your children and grandchildren? Will you cave to the demands of 
Speaker Pelosi, or will you listen to the pleas of the hardworking 
American people who elected you. Join me in this fight for freedom, 
vote ``no.''
  Mr. LEVIN. Madam Speaker, it is now my privilege to yield 1 minute to 
the very distinguished gentleman from Massachusetts (Mr. Neal).
  Mr. NEAL of Massachusetts. Madam Speaker, this is a most significant 
day. Health insurance reform has been coming for a long time, and we 
are finally here. With passage of this bill, American families are 
going to take back control of their health care.
  This bill bars insurance companies from discriminating based on 
preexisting conditions. It caps out-of-pocket expenses. Half the 
bankruptcies in America are due to health-related matters. This bill 
allows individuals and small businesses to purchase affordable 
insurance from competitive marketplaces. It contains cost controls that 
will save the taxpayer $138 billion over the next 10 years. And for 
parents that are watching tonight, your dependents can stay on your 
insurance until they are 26 years old.
  Nobody has defended Social Security and Medicare the way I have in 
this institution. And I must tell you tonight, I can't believe anybody 
who is witnessing this debate would believe for 1 minute that our 
Republican friends have been better in history on Medicare than we have 
been. It is in our DNA. This is a defining moment. The exclusionary and 
discriminatory tactics that exist in our current system tonight become 
history as well.
  Mr. CAMP. Mr. Speaker, I yield 45 seconds to the gentleman from Texas 
(Mr. Brady), a distinguished member of the Ways and Means Committee.
  Mr. BRADY of Texas. The government promised you health care. When 
forced to buy the government-approved plan or face the tax man, you 
complied. But the cost didn't go down, it went up; it's the highest 
ever. It takes now 3 months to see a doctor. And when you need care, 
the government plan denies it four times more often than your insurance 
company. Now the government is short on money. They started rationing 
care, cutting hospital payments, withdrawing coverage from some 
families, and it has just been 3 years since it all began.
  Folks, this isn't the future, this is Massachusetts today. Higher 
costs, slower care, and rationing. That is why Massachusetts said 
``no'' to Obama care. America is saying ``no'' too because bigger 
government doesn't mean better health care.
  Mr. LEVIN. Mr. Speaker, I yield to the gentleman from New York for a 
unanimous consent request.
  Mr. MAFFEI. Mr. Speaker, I submit the remarks for the Record that I 
delivered at the American Cancer Society in East Syracuse on Tuesday of 
this week in support of this historic health care reform bill.
  I have heard from thousands of constituents about the current health 
care reform debate. I've tried to listen to everything they've had to 
say--for and against health care reform. Their advice and their pleas 
and their stories and their criticisms have helped guide my advocacy on 
behalf of changes and improvements to proposals before Congress and my 
decision on the compromise legislation before Congress.
  Now that the President's changes will be incorporated into the final 
legislation, I will support this historic health care reform effort.
  I am voting in favor of this legislation not because I think it is 
perfect, but because I strongly believe it is in the best interests of 
my constituents--that it will make a positive difference in the lives 
of families, businesses, and hospitals in central and western New York.
  First, I'm voting for this because we need to do something to control 
rising health care costs that keep taking a bigger and bigger bite out 
of the household budgets of upstate New York. Skyrocketing health care 
costs aren't just crippling the U.S. economy--they're emptying our 
pocketbooks. My entire life is filled with stories about how people--
regular middle-class people--can't afford the health care they need. 
How insurance companies have denied needed care. How kids graduating 
from college can't find affordable coverage. How people with life 
threatening conditions need to hold bake sales and bowl-a-thons to pay 
health bills. Families go bankrupt not because they were irresponsible 
but because they trusted their insurance plans. More than 72 million 
adults currently have medical debt or problems paying their bills even 
though most of them have insurance. It has to end--and I honestly 
believe if we don't take action now it never will.
  Second, I'm voting for this because if we don't fix health care, 
businesses that are struggling to compete in a global economy will fall 
further and further behind.
  As premiums nearly double, employees in small firms will see offers 
of health insurance options almost cut in half. It is predicted the 41 
percent of firms offering insurance in 2010 will drop to 23 percent in 
2020. Not because they are bad employers but because they cannot afford 
it.
  Every industrialized nation has figured out a way to get people 
affordable coverage--the United States can, too.
  And finally, I'm voting for this bill because the county, state, and 
country are going broke due to health care costs. Sure, we could limp 
along another few years but if we do, it will only be harder to control 
those long-term costs.
  I know many people in my district will be encouraged that we are 
finally moving forward, that we are finally taking action on an issue 
that affects us all.
  I know others will be unhappy. Many of my constituents have strong 
concerns about this legislation. In fact, I share some of those very 
same concerns. I worked very hard to improve this bill. I led the fight 
to hold down the tax on medical devices. I advocated for businesses 
with less than 25 employees to get subsidies for health insurance and 
for a reduced burden on other businesses. I fought successfully to 
raise the threshold on any benefit surcharge so that it won't affect 
middle-class people in my district.
  This is not a perfect bill. But it is an important legislation that 
we need to pass to move this country forward.
  There are several criticisms of the proposal that do come up 
certainly across the country and even here in my district that I feel 
compelled to address.
  First, many argue that this is a government take-over of health care. 
That is simply not true. In fact, except for Medicare, Medicaid, the VA 
and other already existing programs, Americans would be covered by 
private insurance plans. A public option which I support is not even 
included in this plan. There are some additional regulations that give 
more rights to patients such as not allowing health plans to deny 
coverage due to preexisting conditions. But these are widely supported 
and necessary changes. To assert that these new patient rights are some 
sort of government take-over is absurd.
  Second, some will say that large majorities of the American public 
are against the President's plan. The Post-Standard printed an AP poll 
this last weekend that did show slightly more respondents nationwide 
opposed rather than supported the health care reform plans--by two 
percentage points--43 to 41. But for many it's not that the plan went 
too far but that it did not change enough. In fact, fully 82% of the 
respondents to that same poll wanted to change the health system a 
moderate amount or more. Only 17 percent said it should be changed a 
little or not at all.
  So this idea that Americans don't want change is simply wrong. In 
this region, it is particularly misguided. While it is true that my 
office has received many calls objecting to the health care debate, a 
vast majority of them have been from out-of-state--a purposeful and 
well-funded attempt to jam our lines so that my constituents cannot get 
through. And yet thousands did and while it is clear there are diverse 
opinions and that my constituents are more divided on this than any 
other major question we've faced so far, it is also clear from our 
office communications and our research that a majority of my 
constituents want me to work as hard as I can to improve health care 
proposal and support the changes we need. And I will do just that.
  Third, that the President's proposed changes will increase costs to 
businesses and taxpayers. But I ask compared to what? The current 
trajectory is already bankrupting businesses, states, counties, cities, 
and right here in central New York leading to higher and higher 
property taxes. Under the current system, health care will consume one 
of every three dollars in the U.S. economy--twice as much as it does 
today. The President's plan gets these costs under control by 
implementing nearly every idea suggested including

[[Page 4144]]

Republican ideas on medical malpractice and increasing ability to buy 
insurance across state lines. It also over time implements real cuts in 
government spending on health care including eliminating some of the 
waste and subsidies.
  I believe that many of these cost savers will work. I know that doing 
nothing will bankrupt our country and our families and our small 
businesses.
  I know the Republicans in Washington have said that they want to make 
health care the central issue in the elections this coming November. 
Thousands and thousands of dollars have already been spent on ads 
running against me here in central New York. Some of these ads have 
been proven to be false.
  Far from convincing me to oppose the health care reform, they have 
strengthened my resolve. Because when people who have that much money 
feel so strongly that they run attack ads on you, chances are that what 
you're doing is in the best interest of taxpayers and ordinary 
families.
  So what's in this proposal?
  People who have been denied coverage because of a pre-existing 
condition will finally have access to affordable coverage. Insurers 
will no longer be able to drop your coverage when you get sick and are 
in the middle of treatment.
  Never again will you lose access to insurance if you get laid off or 
switch jobs.
  Small businesses and employers getting crushed by soaring health care 
costs will see lower costs.
  Never again will you be subject to annual or lifetime limits on what 
insurance companies will pay, protecting millions of Americans from the 
threat of medical bankruptcy.
  Insurers will be required to offer free preventive care, lowering 
your out-of-pocket expenses and helping ensure that diseases or 
conditions can be caught early on.
  Seniors who fall into the Medicare Part D donut hole will see lower 
prescription drug costs as immediate steps are taken to close the donut 
hole. Employers who cover their early retirees will receive temporary 
funds to help offset the cost of expensive claims for retirees' health 
benefits--lowering premiums and protecting coverage for early retirees.
  Insurers are prohibited from charging women more than men for health 
insurance or discriminating on the basis of domestic violence as a pre-
existing condition. Required maternity services as part of the 
essential benefits package in the exchange.
  Young adults will now be able to stay on their parents' insurance 
much longer, through their 26th birthday.
  And finally, health reform will guarantee access to quality, 
affordable health insurance for 31 million Americans who don't have 
coverage today, also eliminating the annual hidden tax of $1,100 that 
American families pay to cover the cost of the uninsured. While the 
official health insurance exchanges are being created, a temporary 
insurance pool will be available for individuals with pre-existing 
conditions or chronic illnesses.
  These benefits are all vitally important. But perhaps in the end it 
comes down to this: those opposed to health care reform are concerned 
that it will cost them more. This bill saves money and the further out 
you go, the more it saves. But it also saves something more precious--
it will save lives.
  Mr. LEVIN. Mr. Speaker, it is now my real privilege to yield 1 minute 
to the distinguished gentleman from Texas (Mr. Doggett).
  Mr. DOGGETT. So very fearful of being held accountable, the giant 
insurance monopolies have spent millions spewing out anger and 
spreading fear of reform. We have not seen such outlandish, outrageous 
arguments raised since the same forces failed to block President Lyndon 
Johnson from securing approval of Medicare.
  For Republicans, our bill is too long or it is too short. It is too 
thick or it is too thin. It is never just right because their true 
answer to health insurance reform is ``never, never, never.'' Our 
determined efforts should not be derided as a four-letter word, but you 
can certainly sum up our many, many pages with four words: you've got 
health care.
  With this reform, every insured American gets valuable consumer 
protections, and every uninsured American can become insured. Thirty-
two million Americans will be protected from the risk of bankruptcy 
from health care.
  The bill restrains soaring insurance premiums and reduces Federal 
deficits.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. DOGGETT. My time has expired, but many Americans will not, as a 
result of this bill.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore (Mr. Serrano). The Chair will remind all 
Members to heed the gavel.
  Mr. CAMP. Mr. Speaker, I yield 45 seconds to the distinguished 
gentleman from Georgia, Dr. Linder.
  Mr. LINDER. Mr. Speaker, I feel rude trying to inject some fact into 
this kabuki theater, but I am going to try: 85 percent of America is 
insured; 95 percent of those people are happy with their insurance. The 
other 15 percent uninsured, they consume 70 percent on average as much 
insurance as those who are insured. They are cared for. The lady in 
Cleveland who has been referred to ad nauseam is being cared for at the 
Cleveland Clinic.
  So what are we to do about those 15 percent? Why not take over 16 
percent of the economy. A $2.5 trillion program that will destroy 
health care for the 85 percent who are happy, to find health care for 
the 15 percent who are not insured. This has never been about health 
care. This is about government.
  Mr. LEVIN. Mr. Speaker, I yield 1 minute to the very distinguished 
gentleman from California (Mr. Thompson).
  Mr. THOMPSON of California. Mr. Speaker, I have worked for access to 
quality, affordable health care from day one of my very first campaign, 
and every day since.
  Today, with passage of this bill, we will be closer to that important 
goal than ever before. When the President signs this bill into law, 
insurance companies won't be able to drop your coverage if you get 
sick. Kids won't be denied coverage because of preexisting conditions. 
Young adults will be able to stay on their parents' policy until they 
are 26. Small business owners will be eligible for a tax credit. 
Seniors will see the Medicare doughnut hole start to close, and 
preventive care will be covered without copay.
  The bill is paid for and will reduce our debt. In my district, 63,000 
uninsured residents will have access to coverage, and it will save my 
district $70 million in uncompensated care costs. This bill is a great 
start toward health care reform and will help millions of Americans 
afford quality health care.

                              {time}  2000

  Mr. CAMP. Mr. Speaker, I yield 45 seconds to a distinguished member 
of the Ways and Means Committee, the gentleman from California (Mr. 
Nunes).
  Mr. NUNES. Mr. Speaker, this debate is not about the uninsured; it's 
about socialized medicine. Today we are turning back the clock. For 
most of the 20th century, people fled the ghosts of communist 
dictators, and now you are bringing the ghosts back into this Chamber. 
With passage of this bill, they will haunt Americans for generations.
  Your multitrillion dollar health care bill continues the Soviets' 
failed Soviet socialistic experiment. It gives the Federal Government 
absolute control over health care in America.
  My friends, that is what this debate is really about. Today, 
Democrats in this House will finally lay the cornerstone of their 
socialist utopia on the backs of the American people.
  Say ``no'' to socialism. Say ``no'' to totalitarianism. Say ``no'' to 
this bill.
  Mr. LEVIN. It is now my privilege to yield 1 minute to the Chair of 
our caucus, the very distinguished gentleman from Connecticut (Mr. 
Larson).
  Mr. LARSON of Connecticut. I thank the chairman, and it's my honor to 
yield my time to someone who's always understood whose side he's on in 
this debate, the gentleman from Michigan, Mark Schauer.
  Mr. SCHAUER. Mr. Speaker, today I stand for the people of Michigan 
who lost their insurance when they lost their jobs--they've been 
dropped and denied coverage by insurance companies for preexisting 
conditions or because they got sick--and are going broke because of 
their medical bills.
  I stand for the elderly in my district who fall into the doughnut 
hole and must choose between food and medicine, and I stand for small 
businesses who plead for help to put an end to double-digit premium 
increases that

[[Page 4145]]

make them choose between jobs and health care. All of these things will 
end with the passage of this bill.
  The question of the day is: Whose side are you on? I'm on the 
people's side, not on the side of the powerful special interests who've 
spent millions to kill this bill. Cutting through all of the deception, 
misrepresentation, and lies, I stand with the people.
  I urge you to do what's right and vote ``yes.''
  Mr. CAMP. Mr. Speaker, I yield 45 seconds to a distinguished member 
of the Ways and Means Committee, the gentleman from Ohio (Mr. Tiberi).
  Mr. TIBERI. Mr. Speaker, I am for health care reform, but not this 
version. This is a bad bill. It does nothing to address the cost of 
health care. This bill increases taxes on individuals and employers. It 
cuts Medicare and adds debt to future generations.
  But don't take my word for it, Mr. Speaker. My hometown newspaper, 
The Columbus Dispatch, has published three editorials this last week 
against the bill suggesting, and I quote, ``It is incredible that a 
sixth of the U.S. economy and the health of every American could be 
subjected to massive government intervention based on such fiscal 
dishonesty and secrecy.''
  Mr. Speaker, this bill does nothing to reform our health care system. 
It adds people to a broken system.

                           [From Editorials]

                               Add It Up


      on health-care vote, lawmakers should pay heed to the people

       The Obama administration and Democratic leaders in Congress 
     are pushing Democratic members of the House to pass the 
     Senate health-care overhaul in the next week or two and to 
     trust the Senate to agree to changes in follow-up bills that 
     will make the plan more amenable to House Democrats.
       This complicated approach is a parliamentary maneuver 
     intended to deny Senate Republicans the opportunity to kill 
     the bill with a filibuster.
       Of the 11 Democratic members of Ohio's congressional 
     delegation, one is opposed and eight say they are undecided 
     about how they'll vote. Among Ohio's nine Republican members 
     of Congress, there is no ambivalence. All nine plan to oppose 
     it.
       President Barack Obama is pressing hard for the overhaul 
     because it is his signature issue. He is more than a year 
     into his administration and has been handed setback after 
     setback, despite the fact that the White House, House and 
     Senate are in Democratic hands. The economy is stalled, 
     unemployment remains at punishing levels and voters are angry 
     at the lack of improvement. Not only that, but they are 
     alarmed about the serious amounts of debt the government has 
     run up in less-than-stimulating stimulus efforts. The ``blame 
     Bush'' strategy that Obama has employed to date is now a dead 
     horse, unresponsive to further lashing. In short, Obama is 
     desperate for a win.
       Ohio's Democrats must decide whether they were elected to 
     give the American people the best health-care bill possible, 
     or whether they were elected to save a president from a 
     political morass.
       The answer should be easy: they should vote for the 
     American people. That means saying no to the health-care 
     overhaul plans now before Congress. The plans so are have 
     been sold under false pretenses using accounting gimmicks 
     that lowball the costs. They contain no serious mechanisms 
     for controlling the escalation in health-care costs. And 
     extending health insurance to 31 million more Americans would 
     place demands on doctors and hospitals that will drive costs 
     through he roof or necessitate rationing whether it takes the 
     form of denying some treatments or making people wait longer 
     for care.
       The federal government already runs two of the biggest 
     medical programs in the country, Medicare and Medicaid, and 
     both are headed for insolvency. Consider that the health-care 
     overhaul calls for putting half of the 31 million uninsured 
     onto state Medicaid rolls at a time when Medicaid already is 
     driving state budgets into the red.
       If almost half of Ohio's congressional delegation is 
     undecided, the American people are not. Recent opinion 
     surveys find that half or more of Americans oppose the 
     proposed overhaul. The number favoring the plan rarely tops 
     40 percent. No proposal to make over a sixth of the U.S. 
     economy and to radically alter the health-care prospects of 
     all Americans should be rammed through in the face of such 
     opposition.
                                  ____


                              Short Takes

       Congressional Democrats celebrated on Friday after finally 
     unveiling a Congressional Budget Office estimate of the cost 
     of the latest version of their proposed health-care overhaul: 
     $940 billion over the first decade, with a deficit-reducing 
     surplus of $138 billion.
       However, as with previous CBO estimates, the key is in the 
     rules and assumptions Congress required the bean-counters to 
     follow in preparing the estimate.
       And, as before, the rules are gamed to low-ball the costs 
     with assumptions that are dishonest, such as the one that 
     says that the overhaul will be financed in part by squeezing 
     hundreds of billions of dollars in savings from Medicare.
       Everybody in Washington knows that is never going to 
     happen, and that this alone--never mind the other gimmicks in 
     the estimate--pushes the plan into deficit.
       The estimate is dishonest, as is the planned parliamentary 
     dodge the House is likely to use to pass the overhaul without 
     requiring members to directly cast a vote for the Senate bill 
     that forms the core of the plan.
       Meanwhile, President Barack Obama and his aides deny that 
     he is telling balky Democratic House members that they must 
     vote for the measure to save his presidency. But Obama's 
     cancellation of his trip to Asia, which was to begin on 
     Sunday, speaks volumes about what he thinks this vote means 
     to his presidency.
       The administration also denies that Obama has cut any 
     special deals in dozens of private meetings with individual 
     House members over the past week. But neither is the White 
     House divulging many details about these closed meetings.
       It is incredible that a sixth of the U.S. economy and the 
     health of every American could be subjected to massive 
     government intervention based on such fiscal dishonesty and 
     secrecy.
                                  ____

       To better render justice, courts should move at a 
     deliberate speed. But justice delayed is justice denied.
       So, understandably, Ohio Attorney General Richard Cordray 
     is urging the Ohio Supreme Court to move quickly in settling 
     a dispute that will decide whether the state can reclaim $260 
     million in tobacco-settlement money.
       The money, originally slated for anti-tobacco programs, 
     became the center of a legal battle almost two years ago, 
     when the governor and lawmakers sought to divert it for use 
     in an economic-stimulus plan.
       Officials of the Tobacco Use Prevention Foundation tried to 
     thwart the governor by transferring the money to the American 
     Legacy Foundation in Washington, D.C. The governor and 
     lawmakers retaliated appropriately by abolishing the Tobacco 
     Use Prevention Foundation and ever since have been fighting 
     in court for the money to be returned to the state.
       Cordray quite properly argues that as the next biennial 
     budget looms, with huge shortfalls anticipated, state and 
     local officials need to know whether Ohio will be able to 
     count on the tobacco money. Even if the answer is no, at 
     least the decision will end the uncertainty and allow budget 
     planning to proceed.
                                  ____


                      [From the Columbus Dispatch]

                                 Say No


    Health-care overhaul won't reduce costs, will drive up U.S. debt

       Democratic lawmakers in the House are under tremendous 
     pressure to approve within days a massive overhaul of health 
     care. If these members succumb to the pressure from President 
     Barack Obama and Democratic leaders, they will be approving a 
     major intervention into a sixth of the U.S. economy--a move 
     driven by the president's need for a political victory, not 
     by sound policy that serves the interests, wallets and health 
     of the American people.
       Approval of the proposed plan would guarantee that 
     Americans pay more to get less health care. Care ultimately 
     will be reduced, either by raising its cost, by limiting the 
     amount and kind of care available or by making people wait 
     longer.
       Finally, the cost of the new government spending for health 
     care will add to the annual federal deficits and increase the 
     national debt, which already surpasses $12 trillion.
       Though the president claims that the overhaul will reduce 
     the ever-mounting cost of medical care and reduce the federal 
     deficit over 10 years, his numbers are based on accounting 
     tricks, including gaming of revenue and spending estimates 
     and double-counting of various federal revenues.
       The vaunted Congressional Budget Office figures that Obama 
     points to in claiming savings are bogus. The CBO is a by-the-
     books outfit, but it prepares its estimates based on the 
     parameters and assumptions laid down by Congress. If the 
     parameters are dishonest, then the resulting estimate will 
     be, too. In its scoring of the Senate health-care bill, for 
     example, the CBO was required to base its estimate on 10 
     years of tax revenues generated under the plan, but balance 
     that against only six years of spending mandated by the plan. 
     No surprise then, that the estimate shows the cost coming in 
     at less than $1 trillion over its first decade, with a modest 
     surplus. The real question is what the program would cost 
     over a period of 10 years when taxation and spending are 
     fully under way. That number is $2.3 trillion, by one 
     estimate.
       The plan proposes to pay for itself, in part, with $500 
     billion to be cut from Medicare, but Medicare already is 
     headed for insolvency, so money taken from it simply 
     increases Medicare's $38 trillion unfunded liability.

[[Page 4146]]

       In December, the chief actuary for the federal Centers for 
     Medicare and Medicaid Services reported that the Senate plan 
     does nothing to curb increases in costs and actually would 
     make those costs higher than they would be without the 
     overhaul.
       Adding 31 million people to health-insurance rolls, as the 
     bill seeks to do, will increase the lines waiting to see a 
     doctor or to enter a hospital for treatment. This massive 
     increase in demand also will drive up the cost of care. The 
     president has promised that those content with their current 
     insurance coverage won't have to change it, but the 
     circumstances under which they exercise that coverage are 
     going to change significantly. Expanding to vastly the pool 
     of people with health insurance is going to mean sacrifices 
     in affordability and access for everyone.
       Half of the 31 million are to be enrolled in state Medicaid 
     programs, at a time when Medicaid has become the Pac-Man of 
     state budgets, swallowing billions in state revenues each 
     year at a accelerating rate. Meanwhile, many doctors already 
     refuse to take on additional Medicaid patients, so where will 
     the millions of new Medicaid enrollees find care?
       Under the proposal, medical costs, health-care premiums, 
     annual federal deficits and the national debt would 
     increase--the direct opposite of the president's promise that 
     it would provide Americans with affordable health care that 
     improves the government's bottom line.
       The Senate bill that the House is being asked to approve 
     also contains all the backroom political payoffs to favored 
     lawmakers that so enraged the nation when the measure was 
     passed by the Senate, such as the ``Cornhusker kickback,'' 
     negotiated by Nebraska Democratic Sen. Ben Nelson, which 
     would have the federal government pick up the increased costs 
     of Medicaid expansion in his state, while leaving Ohio and 
     other states to squeeze more revenue out of state taxpayers.
       Obama has proposed to eliminate the Nebraska giveaway and 
     have the federal government provide more but not all the 
     money states will need to cope with large Medicaid rolls. But 
     even if the Nelson bribe ultimately is nixed, news reports 
     say that more special deals were being cut this week to 
     induce House members to vote yes.
       Labor unions also have been promised a massive perk: Their 
     members would be exempt from the bill's tax on high-end 
     ``Cadillac'' health-care plans until 2018, saving unionized 
     employees $60 billion during that period. Meanwhile, nonunion 
     workers will be stiffed for an estimated $90 billion in new 
     taxes.
       Equally unsavory is the so-called ``Slaughter solution,'' a 
     parliamentary trick by which House members could approve the 
     Senate plan without casting a direct vote for it. If, as the 
     president says, the American people are clamoring for his 
     health-care overhaul, why should Democratic lawmakers fear 
     voting for it?
       The answer is that lawmakers know that the majority of the 
     American people are not clamoring for this particular 
     overhaul, as one opinion survey after another shows. 
     Americans want health-care reform, but not the sort that 
     congressional leaders and the president hope to force down 
     their throats in the next day or two.

  Mr. LEVIN. It is now my real privilege to yield to another member, an 
energetic member of our committee, the gentleman from Wisconsin (Mr. 
Kind).
  Mr. KIND. Mr. Speaker, I will never forget the pride I felt as a 6-
year-old kid in Wisconsin watching Neil Armstrong and Buzz Aldrin walk 
on the moon. It was a deep and abiding belief that I live in a country 
that's capable of accomplishing anything once we put our mind to it. 
That belief is being tested throughout America today.
  People are wondering if we're still capable of doing great things. I 
believe we can, and I want my two boys to feel the same way. I believe 
our country, by working together, can ensure that all Americans have 
access to quality, affordable, and secure health care, regardless if 
they're young or old, whether they're rich or poor, and even whether 
they have a preexisting condition. And we can do this in a fiscally 
responsible manner by paying for this bill and finding savings that 
will reduce the deficit in future years.
  That national achievement can begin today, this evening, with our 
vote. I encourage my colleagues to support this health care reform for 
all Americans.
  The SPEAKER pro tempore. The Chair will note that the gentleman from 
Michigan (Mr. Camp) has 4\1/2\ minutes remaining and the gentleman from 
Michigan (Mr. Levin) has 6\3/4\ minutes remaining.
  Mr. CAMP. Mr. Speaker, I reserve the balance of my time.
  Mr. LEVIN. It is now my privilege to yield 1 minute to our vice Chair 
and the distinguished gentleman from California, Xavier Becerra.
  Mr. BECERRA. Mr. Speaker, today is a day of history. Today we will 
accomplish what 100 years of Congresses could not. We will pass health 
care reform, not just for some, but for all Americans.
  Today is also another day in America. That means that 123 Americans 
will die today because they do not have health insurance. Another 8,000 
will lose their health insurance today, and our health care system will 
cost all of us $6.8 billion this day and every day if we do not change, 
if we are content with doing nothing.
  John F. Kennedy once said, ``Change is the law of life, and those who 
look only to the past or present are certain to miss the future.'' I've 
heard it said another way: The only human institution which rejects 
progress is the cemetery.
  Today this House, the people's House, is full of life. We will make 
history, but our sights are toward the future. To every hardworking, 
taxpaying American, we say today, We hear you. We see it in your eyes. 
You want control of your health care. You want to decide who your 
doctor is. You want to choose your health plan. We will deliver today 
to all of America.
  Mr. CAMP. Mr. Speaker, at this time I yield 45 seconds to a 
distinguished member of the Ways and Means Committee, the gentlewoman 
from Florida (Ms. Brown-Waite).
  Ms. GINNY BROWN-WAITE of Florida. Mr. Speaker, the Democrats on the 
other side of the aisle believe that the American citizens can no 
longer be trusted to manage their own health care in the best way that 
they see fit. You must now do things in their socialist way or face the 
wrath of the IRS.
  Unfortunately, the size of the Federal Government isn't the only 
thing that's going to grow as a result of this bill. So will your 
insurance premiums, because the cost of insurance will grow. That's 
right. The bill increases premiums for every American who has 
insurance. Our national debt will grow. Your taxes will grow.
  The only thing that won't grow are the benefits that the seniors who 
are in the Medicare Advantage plan have. They will be losing their 
doctors because doctors are refusing to take Medicare patients and will 
once this bill becomes law.
  Mr. Speaker, this bill cuts Medicare, raids Social Security, and we 
need to reject this bill.
  Mr. LEVIN. I now yield 1 minute to the gentleman from New Jersey (Mr. 
Pascrell).
  Mr. PASCRELL. Mr. Speaker, many things are said across the aisle in 
the heat of a debate, and if it hasn't been said yet, maybe the reason 
is it has been said by everybody.
  I believe that the ranking member is an honorable person. I believe 
my chairman is. * * * Even the President of the Vietnam Veterans of 
America said this is shameless.
  *  *  * It's not right. Tell the truth and then let the chips fall 
where it may. It is utterly * * * to suggest, Mr. Chairman, that we are 
seeking to deny any soldier the health care they deserve and the 
benefits that nearly all Republicans and Democrats have spent our 
careers in Congress working to protect and prove.
  Mr. DAVIS of Kentucky. Mr. Speaker, I ask the gentleman's words be 
taken down for the false statements that he made about this conference 
to me as an Army veteran among others in the Chamber.
  The SPEAKER pro tempore. The gentleman from New Jersey will be 
seated.
  The Clerk will report the words.
  Mr. PASCRELL. Mr. Speaker, I ask unanimous consent to remove any word 
or words that were taken as offensive.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from New Jersey?
  Mr. DAVIS of Kentucky. I accept the gentleman's apology.
  The SPEAKER pro tempore. Without objection, the words will be 
stricken.
  There was no objection.
  Mr. PASCRELL. Don't push me.
  I include the following material for the Record:

[[Page 4147]]

                                  Vietnam Veterans of America,

                                                   March 21, 2010.

 Vietnam Veterans of America Applauds Passage of Skelton Bill Ensuring 
  Protection of TRICARE, VA Health Care, and CHAMPUS; Decries ``Scare 
                               Tactics''

       Washington, DC.--``We thank and applaud passage of H.R. 
     4887 yesterday in the House of Representatives, by a vote of 
     403-0. Passage of this bill ensures that health care programs 
     for veterans, active duty military, retired military, and 
     their families/survivors will not be affected negatively by 
     the pending health care reform legislation.'' said John 
     Rowan, National President of Vietnam Veterans of America 
     (VVA).
       ``It is unfortunate that some continue to raise what is now 
     is even more clearly a false alarm that is apparently meant 
     to frighten veterans and their families in order to prompt 
     them to oppose the pending legislation. While there is 
     legitimate debate as to whether or not the pending health 
     care measures should become law, VVA does not appreciate 
     spreading rumors that are not accurate by any political 
     partisan from any point of the political spectrum.'' 
     continued Rowan.
       ``Last summer there was a similar incident, also involving 
     partisans in the health care reform debate that VVA soundly 
     condemned. We said then: ``It is our hope that sane minds 
     reject fear-mongering, and that veterans recognize these 
     scare tactics for what they are,'' Rowan said. Rowan 
     concluded by saying ``VVA has always worked hard for justice 
     for veterans of all generations, and their families. We have 
     always, and will continue to, work with public officials 
     representing all political parties and points of view. Issues 
     affecting veterans and their families are not, should not, 
     and must not become partisan footballs to bat around. VVA 
     decries any effort, by anyone, that would do just that.''
                                  ____


                    Department of Veterans Affairs,

                                                   March 21, 2010.

              Statement From VA Secretary Eric K. Shinseki

       As Secretary of Veterans Affairs, I accepted the solemn 
     responsibility to uphold our sacred trust with our nation's 
     Veterans. Fears that Veterans health care and TRICARE will be 
     undermined by the health reform legislation are unfounded. I 
     am confident that the legislation being voted on today will 
     provide the protections afforded our nation's Veterans and 
     the health care they have earned through their service. The 
     President and I stand firm in our commitment to those who 
     serve and have served in our armed forces. We pledge to 
     continue to provide the men an women in uniform and our 
     Veterans the high quality health care they have earned.
       President Obama has strongly supported Veterans and their 
     needs, specifically health care needs, on every major issue 
     for these past 14 months--advance appropriations, new GI Bill 
     implementation, new Agent Orange presumptions for three 
     additional diseases, new Gulf War Illness presumptions for 
     nine additional diseases, and a 16% budget increase in 2010 
     for the Department of Veterans Affairs, that is the largest 
     in over 30 years, and which has been followed by a 2011 VA 
     budget request that increases that record budget by an 
     additional 7.6%.
       To give our Veterans further assurance that health reform 
     legislation will not affect their health care systems, the 
     Chairmen of five House committees, including Veterans Affairs 
     Chairman Bob Filner and Armed Services Chairman Ike Skelton, 
     have just issued a joint letter reaffirming that the health 
     reform legislation as written would protect those receiving 
     care through all TRICARE and Department of Veterans Affairs 
     programs.
                                  ____



                                Congress of the United States,

                                   Washington, DC, March 21, 2010.
     Hon. Louise Slaughter,
     Committee on Rules, The Capitol, Washington, DC.
       Dear Chairwoman Slaughter: The House Democratic leadership 
     asked our committees to review HR 3590 and HR 4872 to assess 
     the impact of the bills on the health care provided by the 
     Department of Defense and the Department of Veterans Affairs. 
     Our reviews of HR 3590 and HR 4872 lead us to believe that 
     the intent of the bills was never to undermine or change the 
     Department of Defense and Department of Veterans Affairs 
     operation of their health care programs or interfere with the 
     care that our service members receive under TRICARE. However, 
     we commit to look into this issue further to ensure that no 
     unintended consequences may arise and to take any legislative 
     action that may be necessary.
       HR 3590, as drafted, does not specifically mention that 
     TRICARE coverage meets the individual responsibility 
     requirement, but such coverage would satisfy the requirements 
     of this bill. To affirm that this is the case, the U.S. House 
     of Representatives unanimously passed HR 4887, the TRICARE 
     Affirmation Act, which provides assurances to the American 
     people that care provided to those in the military and their 
     families, as well as military retirees under age 65 and their 
     families, would indeed meet the requirement for coverage.
       The members of our nation's military sacrifice much to 
     defend us all. We commit to these dedicated service members 
     and their families as well as our veterans that we will 
     protect the quality healthcare they receive.
           Sincerely,
     Bob Filner,
       Chairman, Committee on Veterans' Affairs.
     Ike Skelton,
       Chairman, Committee on Armed Services.
     Sander Levin,
       Chairman, Committee on Ways and Means.
     George Miller,
       Chairman, Committee on Education and Labor.
     Henry Waxman,
       Chairman, Committee on Energy and Commerce


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair reminds all Members that any 
statements should be directed through the Chair and not to others in 
the second person.


                         Parliamentary Inquiry

  Mr. TIAHRT. Parliamentary inquiry, Mr. Speaker,
  The SPEAKER pro tempore. The gentleman from Kansas will state his 
parliamentary inquiry.
  Mr. TIAHRT. Is it true that in the course of comfortable debate that 
we not question another Member's motives?
  The SPEAKER pro tempore. The Chair will affirm that Members must 
maintain proper standards of decorum.
  Mr. TIAHRT. Is it against the House rules to question another 
Member's motives?
  The SPEAKER pro tempore. A Member's remarks should avoid 
personalities toward other Members.
  Mr. TIAHRT. I thank the Speaker.
  Mr. CAMP. Mr. Speaker, I yield 45 seconds to a distinguished member 
of the Ways and Means Committee, an Army Ranger, Mr. Davis of Kentucky.
  Mr. DAVIS of Kentucky. My heart is heavy with grief tonight at this 
turning point for our Nation, Mr. Speaker. This vote will define the 
America we will have in the future: massive tax burdens, rationed care, 
and intrusive bureaucracy.
  Democrats are thwarting the will of the American people, taking them 
on a headlong rush toward socialism. This is based on a false premise 
that every need a person could have on Earth can be met by government. 
Almost like worshipers, they carry the heart of our Constitution, 
bought in blood, and sacrifice it on the altar of political expediency. 
It raises taxes, violates your privacy, is policed by the IRS, intrudes 
on free choice, and hurts seniors.
  I stand firm in my opposition to this exercise in idolatrous statism, 
a true tyranny that is the largest legislative transfer of power to the 
executive branch in the history of this Republic.
  Vote ``no'' on this bill. Start over with real reforms that Americans 
want.
  Mr. LEVIN. It is now my pleasure to yield 45 seconds to the very 
distinguished gentleman from New York (Mr. Crowley).
  Mr. CROWLEY. Mr. Speaker, I rise in support of the Patient Protection 
and Affordable Health Care Act, a historic measure that will put 
families first when it comes to accessing health care coverage.
  American families need this bill now more than ever. In the past 
decade, the cost for health care for American families has skyrocketed. 
If we do nothing, it's only going to get worse. If we do nothing, in 10 
years small businesses will shell out $29,000 in medical costs per 
employee. If we do nothing, the costs of an employer-sponsored health 
insurance plan will increase 84 percent by 2016. And if we do nothing, 
the American economy will break under the weight of mounting debt.
  Americans may very well be tired of the endless media coverage 
regarding this debate. But they know as we do that we have a serious 
problem in our health care system that must be fixed. We on this side 
of the aisle are ready to deal with it.
  Simply put, health care reform is good medicine for America and good 
medicine for American businesses.
  The SPEAKER pro tempore. The time of the gentleman has expired.

[[Page 4148]]




                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will remind both sides to heed the 
gavel.
  Mr. CAMP. Mr. Speaker, at this time I yield 45 seconds to a 
distinguished member of the Ways and Means Committee, the gentleman 
from Washington (Mr. Reichert).
  Mr. REICHERT. Mr. Speaker, the American people have spoken loud and 
clear. They don't want a government takeover of health care. The 
Democrats' latest plan is still a government takeover. Billions of 
dollars in new taxes on small businesses, over a trillion dollars in 
new spending, and it hurts our seniors and special-needs population by 
taxing hearing aids, pacemakers, wheelchairs.
  We've heard, ``If you like it, you can keep it.'' Not according to 
this President, who said recently, ``I think some of the provisions 
that got snuck in might have violated that pledge.''
  We need to start over, and today I stand with Americans who want the 
freedom to choose their own health care.
  Mr. LEVIN. I yield for the purpose for a unanimous consent request to 
the gentleman from North Carolina (Mr. Etheridge).
  Mr. ETHERIDGE. Mr. Speaker, I rise on behalf of a young man by the 
name of Will Privitt who tonight will be able to get insurance for the 
first time. He was born with a preexisting condition.
  Mr. Speaker, I rise today in support of health reform. I have said 
all along that there are several goals that our efforts must meet to 
improve security and stability for North Carolinians. We need to reform 
health insurance to reduce costs for people who have insurance and 
those who have been priced out of the market. We need to increase 
consumer choices and make sure that insurance companies do not deny 
coverage because of preexisting conditions or technicalities. We need 
to shore up Medicare to improve security for seniors, reducing costs 
for medications and eliminating copayments. We need to make insurance 
affordable for businesses, so that they are not faced with the choice 
of providing coverage for their employees or making payroll. Finally, 
we must put discipline back in the budget and bring down the budget 
deficit. I rise in support of H.R. 4872, the Health Care and Education 
Affordability Reconciliation Act of 2010 and H.R. 3590, the Patient 
Protection and Affordable Care Act because together they meet these 
goals.
  The working families of the Second District need solutions, not more 
fear, neither the real fears of rising cost nor the false fears spread 
by special interests. We cannot continue to allow the current system to 
kill jobs and bust the budgets of our families and our Nation. After 
reading the legislation carefully, I have concluded that it will save 
lives and save money. This is the best chance we have to reduce sky-
rocketing health care costs for North Carolina families.
  North Carolinians know that the current system is broken and that we 
need commonsense reform. For me, the effort to fix our health care 
system has always been about people not about politics. Our effort is 
about North Carolina families. We need reform for folks who are 
struggling with unbearable health care costs, rapidly rising premiums, 
bureaucratic meddling, and arbitrary denials of coverage and a system 
that is driving our Nation deeper and deeper into debt.
  Throughout this process, I have heard from thousands of folks from 
the main streets and country roads of North Carolina who are crying out 
for help. At numerous town hall meetings in North Carolina and over the 
telephone, as well as in other opportunities, I have spoken directly to 
North Carolinians. I read thousands of messages that come in by phone, 
email, fax, or letter every day. The vast majority say that change is 
needed.
  When North Carolina families are hurting, doing nothing really isn't 
an option for me. I have heard from thousands of my North Carolina 
neighbors who are suffering under the current system.
  Folks like a nurse from Sanford, North Carolina, who says that 
insurance industry bureaucrats are keeping her from providing her 
patients the care they need.
  Folks like a woman from Raleigh, who fears she will suffer the same 
fate as her sister who died from asthma because she could not get 
insurance coverage.
  Folks like a man from Louisburg, who cannot start a new business 
because he needs the insurance his current employer provides. His 
mother pleaded with me that they are not looking for a handout; just a 
fair playing field.
  Folks like a woman from Rocky Mount, who notes that the working poor, 
self-employed, part-time workers and others on the margins need relief. 
She called on me to not let the insurance companies win this time.
  These are the real people that convinced me that voting for these 
bills is the right thing to do. A lot of folks are afraid, both of the 
current system and of potential changes. Thousands of families without 
insurance, and individuals with pre-existing conditions, are an illness 
away from financial ruin. Reform needs to provide them security.
  Mr. Speaker, as we continue to address America's financial situation, 
health reform is absolutely necessary to get our economy growing again. 
This bill will reduce the stranglehold that insurance costs have on our 
small businesses and eliminate the threat of bankruptcy due to medical 
costs that hangs over so many North Carolina families. It will 
strengthen our rural communities, supporting the training of doctors 
and providing incentives for them to work in underserved areas. And the 
bill is fully paid for, so that not only will it bring down costs for 
individuals and businesses, but for the taxpayer and future 
generations.
  Mr. Speaker, making sure every American has access to affordable 
health insurance and high-quality health care is one of the most 
important challenges of our time. If we can afford to provide health 
care to Iraqi citizens, as we have over the past decade, we can afford 
a fiscally responsible reform that puts health care in reach for all 
Americans. The health reform debate is about saving money and saving 
lives. At its core, health reform is all about ensuring that American 
families and businesses have more choices, benefit from more 
competition, and have greater control over their own health care, while 
bringing down costs for individuals, our families and businesses, and 
for the Nation.
  These bills are fiscally responsible and will improve the health and 
health care of people across my district, North Carolina, and the 
country. I am pleased to be able to vote in favor of this historic 
legislation.
  The SPEAKER pro tempore. The gentleman from Michigan will be charged 
time.
  Mr. LEVIN. I yield to the gentleman from Pennsylvania (Mr. Fattah) 
for a unanimous consent request.
  Mr. FATTAH. I rise in support of the health care reform bill in honor 
of a friend of mine, Linda Taylor, who died because of the lack of 
insurance in a breast cancer illness that she faced.
  Mr. Speaker, I would like to take the opportunity to mark the passage 
of this historic legislation and to thank the individuals whose hard 
work made this moment possible. Of course we would never have gotten 
here without the perseverance of our Speaker, Nancy Pelosi, Majority 
Leader Steny Hoyer, and Majority Whip, Jim Clyburn. Also, Congressman 
John Larson, Chair of the Democratic Caucus and Xavier Becerra, Vice 
Chair. I would also like to thank Congressman Chris Van Hollen for his 
leadership and the Committee and Subcommittee Chairs whose perseverance 
brought us to this historic vote today: Chairmen George Miller from 
Education and Labor, Charlie Rangel from Ways and Means, Henry Waxman 
from Energy and Commerce and Sander Levin from Ways and Means and 
Subcommittee Chairs Pete Stark from Ways and Means and Frank Pallone 
from Energy and Commerce. I would especially like to thank my regional 
colleagues, Education and Labor Subcommittee Chairman Bob Andrews, 
Budget Committee Vice Chair Allyson Schwartz, House Administration 
Chairman Bob Brady, Congressman Mike Doyle, Congressman Patrick Murphy 
and Congresswoman Barbara Lee and Delegate Donna Christensen who 
represented the Congressional Black Caucus in critical negotiations. 
This bill will be good for my District, our region, and our country. We 
in the Congress owe a debt of gratitude to our President, Barack Obama, 
who led this historic effort.
  I would be remiss if I didn't thank the staff whose talents are 
rarely seen in public, but without whom this would never have happened. 
First, Liz King in my office, an ardent advocate for my constituents in 
this debate. In the White House, Nancy-Ann DeParle whose institutional 
memory and long-term commitment to healthcare access for all 
contributed to the success of this effort. Cheryl Parker Rose and 
Wendell Primus in the Speaker's office, Catherine Tran in the 
Democratic Caucus, Debbie Curtis and Cybele Bjorklund on the Ways and 
Means Health Subcommittee, Michele Varnhagen on the Education and Labor 
Health Subcommittee and Karen Nelson on the Energy and Commerce Health 
Subcommittee staff.
  On the local level, I would like to extend my appreciation to Marc 
Stier at Health Care for

[[Page 4149]]

America NOW and Bob Brand a close friend, local advocate and veteran in 
this fight. I would also like to thank the countless constituents who 
called my Washington and Philadelphia offices, sharing their stories 
and raising their voices on behalf of health reform for themselves and 
their neighbors.
  I want to thank and congratulate each and every one of them for 
getting this bill to this point and for giving me the opportunity to 
vote for affordable, secure healthcare for America's families.
  The SPEAKER pro tempore. The gentleman from Michigan will be charged 
time consumed.
  Mr. LEVIN. I yield 45 seconds--I wish I could yield more--to our 
distinguished colleague from Maryland (Mr. Van Hollen).
  Mr. VAN HOLLEN. Mr. Speaker, they called it ``a dangerous device 
invented in Nazi Germany'' and a ``method of imposing Stalinism.'' 
Those were the statements made by the opponents of Medicare, Medicare 
that now provides health coverage to 45 million Americans.
  This legislation will ensure that 32 million more Americans have 
access to affordable health care and that no American is held hostage 
to the abusive practices of the insurance industry.
  As in 1965, we have the rhetoric of mass distortions. This morning, 
Republican Leader Boehner even said this bill means Armageddon. The day 
after this legislation is signed by President Obama, Americans will see 
the world is not coming to an end, that there are no death panels. They 
will begin to see a system that works for them, not the insurance 
industry who is spending millions of dollars to kill the bill.
  Mr. CAMP. At this time, Mr. Speaker, I yield 45 seconds to a 
distinguished member of the Ways and Means Committee, Dr. Boustany of 
Louisiana.
  Mr. BOUSTANY. Mr. Speaker, we all have compassion for families 
struggling, those who have lost jobs, those who lack access to health 
care. We all want to do what's right for our country. We all want to 
solve these problems. But as I look at this massive, complex and 
partisan bill, I see premiums continuing to rise for families and 
abject failure to control health care costs for families and 
businesses.
  I see huge tax increases coupled with irresponsible cuts to Medicare 
services, all to expand new coverage entitlements where physician 
access will worsen, continuing to burden our strapped emergency rooms.
  Mr. Speaker, frankly, I see a sequel to the modern Greek fiscal 
tragedy unfolding before us with a potential for default. We have a 
duty to reform health care, but an obligation to get it right.
  Mr. LEVIN. I now yield 45 seconds to a very senior member of our 
committee, Mr. McDermott of Washington.
  Mr. McDERMOTT. Mr. Speaker, there are times in history that action is 
demanded. In 1935, we needed Social Security and unemployment 
insurance. The Democrats answered. In 1965, we needed health care for 
senior citizens. The Democrats answered. In 2010, the country needs 
health care reform, and the Democrats will answer tonight.
  It was never in doubt. Business wanted a change, the medical 
profession wanted a change, and labor wanted a change. And the 
Republicans brought an economic collapse to make it clear to everybody 
that we all are in danger if we don't change the health care system in 
this country.
  For me and many of my colleagues, passing a national health care 
reform bill is the culmination of a long process. In the late 1950s and 
early '60s, when I was going to medical school in Chicago, Canada's 
Tommy Douglas was beginning a national health care plan in the province 
of Saskatchewan. As I came to the end of my medical training, doctors 
began to strike in Canada because they didn't want to practice medicine 
under any system that was not totally free enterprise in nature. But as 
a new physician at the time, it seemed to me that the benefits of 
extending health coverage to everyone in Canada far outweighed the 
benefits of a free enterprise system. Between 1963 and 1970, while I 
got my training in adult and child psychiatry and served 2 years in the 
United States Navy, I had the opportunity to observe the American 
healthcare ``nonsystem'' firsthand. Every day, I watched as people fell 
through the cracks. When I entered politics in the Washington state 
legislature, I knew that it was my obligation to do all that I could to 
bring about a national system that would provide coverage for everyone. 
And during my campaign for governor in 1972, I made my first speech 
declaring my support for a single-payer system similar to Canada. Each 
year that I served in the state legislature, I faced the institutional 
resistance to the creation of a more orderly system. Yet people 
complained they couldn't get care. Hospitals complained about 
uncompensated care. People complained about cost shifting of the 
expenses of the uninsured onto the policies paid for by the insured.
  In the early 1980s, I began trying to establish an uncompensated care 
fund that would be paid into by all hospitals and the receipts would be 
given to those hospitals that took care of those in the community who 
had no health insurance. But hospitals resisted. I did a study to find 
out how many people in the state of Washington either were not covered 
by a government program or didn't have insurance through their 
employment. Unsurprisingly, we found that it was a huge number. So in 
1983, I began the process of trying to do in Washington State what 
Tommy Douglas had done a few hundred miles away in the province of 
Saskatchewan.
  As I tried to get universal coverage in the state of Washington, I 
ran into numerous obstacles. The medical establishment was more 
interested in capital investments than they were in ensuring that 
medical coverage was available to everyone in Washington. Large 
businesses were reluctant to accept any responsibility beyond what they 
were already doing for their employees. Any mandate was out of the 
question because under a technical loophole, big employers are exempt 
from many regulations that deal with insurance. So instead, I ended up 
authoring the Washington State Basic Health Plan, which is a subsidized 
health insurance program to help lower-income families afford coverage. 
But I wasn't able to get universal coverage.
  This experience taught me that it was going to be incredibly 
difficult to create a health care plan in one state that could be 
replicated across the country as had been done in Canada. I wrote the 
plan originally when the governor of the state of Washington was a 
Republican, so it didn't get anywhere until Democrat Booth Gardner was 
elected governor of Washington in 1984. The process was so frustrating 
and the final legislation so modest that I decided I'd go back to 
medicine. I went to work for the State Department in Africa, where I 
saw the beginnings of the AIDS epidemic in 1987.
  One day my brother called me when I was in Africa and told me there 
was a seat open in Congress. He suggested that I return to the U.S. to 
run for the seat and work on getting universal health care. The dream 
was not dead, it has just been dormant. So I returned, ran for Congress 
and was elected in 1988. I made the decision to get on the Ways and 
Means Committee because I thought that was where I could be most 
effective in getting a national plan established. I was appointed to 
the committee in 1991 and began working with 95 other members who were 
dedicated to a single player plan. In 1993 President and Mrs. Clinton 
came to Washington to enact a national health plan, but we were 
unsuccessful.
  The years between 1994 and 2006 were a painful period as we watched 
Republicans try to dismantle the only national health care program we 
have, Medicare. We breathed a great sigh of relief at the 2008 election 
of President Barack Obama, who stated that he wanted to enact a 
national health plan. The President was determined not to repeat the 
errors of the Clinton administration, and the process of writing the 
bill has been long and tortuous. Over the course of many months, we've 
watched this bill wind through three committees in the House and two 
committees in the Senate, which brought us to where we are today.
  I still believe that a single-payer model is the most effective to 
achieve both cost control and universal coverage. But 40 years of 
experience prevent me from being ideological about the solution to the 
problems of universal coverage. Rather than establishing a single-payer 
system, Congress has designed a less desirable model that would more 
tightly regulate private insurance companies much in the same way that 
we do with utility companies. Members of Congress have opted for a 
model that provides for insurance regulation at the national level, 
rather than the state level as it is today. It has much in common with 
the French system which provides universal coverage to the French 
people at half the cost of what we spend here in the United States. 
Their system provides a quality of care that is considered the best in 
the world according to the World Health Organization.

[[Page 4150]]

  I know that this bill is far from perfect and will require continued 
efforts to adjust and improve it in the years to come. But today we 
began. As the Chinese adage says, ``every journey of 1,000 miles begins 
with a single step.'' Today we have taken that step.
  Mr. CAMP. Mr. Speaker, I yield 45 seconds to a distinguished member 
of the Ways and Means Committee, the gentleman from Nevada (Mr. 
Heller).
  Mr. HELLER. I thank the gentleman for yielding.
  Thousands of Nevadans have been surveyed and an overwhelming number 
oppose the government takeover of health care. Yet two-thirds of 
Nevada's delegation will defy their constituents and vote with their 
leadership instead.
  This $2.6 trillion legislation will raise Nevada taxes, kill Nevada 
jobs, remove Nevada seniors from Medicare, and saddle the State of 
Nevada with budget-busting mandates. I urge my colleagues from Nevada 
to speak for Nevada--not their Beltway benefactors--when casting their 
vote today.
  Mr. LEVIN. I now yield 45 seconds to the gentleman from Oregon, a 
member of the committee, Mr. Blumenauer.
  Mr. BLUMENAUER. Today's victory for health care reform and coverage 
for 32 million Americans is not just the culmination of 15 months of 
hard work in this Congress. It represents the historic accomplishments 
sought by Presidents and Members of Congress dating back to Teddy 
Roosevelt. That the accomplishment was achieved in the midst of 
difficult economic times, a toxic political environment without any 
bipartisan support, makes it all the more remarkable.
  Passage tonight will start making a difference for our families this 
year and, most important, the bill is fully paid for. We're reforming 
Medicare, we improve the quality of health care in this country and 
reduce the deficit. Tonight's victory starts America on the road to 
better health and economic security.
  Mr. CAMP. Mr. Speaker, before I yield, I would like to remind the 
Chair that Medicare and Social Security passed with large bipartisan 
majorities.
  With that, I yield 45 seconds to the distinguished member of the Ways 
and Means Committee, the gentleman from Illinois (Mr. Roskam).
  Mr. ROSKAM. I thank the gentleman for yielding.
  Mr. Speaker, just because it's historic doesn't mean it's good. I 
think we've got to be reminded of that. I think back to history for 
something that actually was good, and that was when Alexander Hamilton 
said regarding our Constitution, ``Here, sir, the people govern.''
  We would be wise to listen to the American people. The American 
people have said ``no'' to the ABCs of PelosiCare. They have said 
``no'' to the arrogance of this bill. They have said ``no'' to the 
budget-busting nature of this bill. And they have said ``no'' to the 
crippling of the economy of this bill.
  In Illinois, a manufacturer called Caterpillar said that next year 
alone it will cost the company a hundred million dollars. What does 
that do to a State that is left roughshod by overpromises and 
underdelivering on a stimulus that failed?
  The SPEAKER pro tempore. The Chair will note that the time of the 
gentleman from Michigan (Mr. Camp) has expired. The gentleman from 
Michigan (Mr. Levin) has 1\1/2\ minutes remaining.
  Mr. LEVIN. I now yield 45 seconds to the distinguished gentleman from 
Illinois (Mr. Davis).
  Mr. DAVIS of Illinois. Mr. Speaker, as I was growing up, our parents 
always taught us that right was right if nobody was right and that 
wrong was wrong if everybody was wrong. Well, I can tell you it would 
be wrong to deny 32 million additional Americans the right to health 
insurance coverage. It would be wrong to keep people cooped up in 
institutions when they could live at home. It would be wrong to keep 
senior citizens struggling to try and pay for their prescriptions.
  Let's do the right thing. Let's vote for this legislation. Give 32 
million people the right to have insurance coverage. Let's do the right 
thing.
  Mr. Speaker, when I was growing up my parents taught us that right 
was right if nobody was right and that wrong is wrong is everybody is 
wrong. It would be wrong to deny 32 million people health insurance 
coverage. It would be wrong to deny millions of people with pre-
existing conditions the right to have insurance coverage.
  It would be wrong to keep filling up the emergency rooms of hospitals 
because people don't have regular doctors. It would be wrong to keep 
senior citizens struggling to pay for their prescriptions. It would be 
wrong to keep people with disabilities cooped up in institutions when 
they could live at home. It would be wrong to deny people health 
coverage because they have lost their jobs. It would be wrong to deny 
health coverage to people who work in small businesses.
  It is right to provide coverage to as many people as we can. It is 
right to reduce the deficit and save as much money as we can. It is 
right to save lives. It is right to do the right thing. It is right to 
vote to pass this bill and provide health coverage for 32 million 
additional Americans.
  It is right to do the right thing.
  Mr. LEVIN. I now yield to the gentlelady from New York for a 
unanimous consent request.
  Mrs. MALONEY. I thank the gentleman for yielding and for his 
leadership.
  I rise in support of the health care bill.
  Mr. Speaker, this is an historic vote. With passage of these health 
care reforms, 32 million people without insurance will get it--
including almost 2.5 million uninsured in New York State.
  It will end discrimination for preexisting conditions, make progress 
on cutting high medical costs, and reduce the deficit by over $1 
trillion over the next two decades.
  This package of reforms that will make a real difference in the lives 
of Americans, over their entire lives:
  If you're 21 and just graduating college, you'll now be included on 
your parents' coverage until your 26th birthday.
  If you're self-employed in your thirties or forties, you'll be able 
to shop for more affordable coverage on exchanges set up by states or 
the Federal Government.
  If you're 56 and have taken early retirement, you can continue to be 
covered under your employer's plan until you sign up for Medicare.
  And if you're a senior with Medicare Part D Drug Coverage, the so-
called ``donut hole'' has been closed.
  The Senate version penalized states like New York which were already 
doing more than most to provide care to the needy. And that's one of 
the things this House is fixing.
  The impact on the New York State Medicaid budget went from a 
projected increased cost of over $700 million to increased aid of $1.3 
billion in just the first year. That's a ``swing'' of over $2 billion.
  Finally, these reforms will do more for women's health despite the 
restrictive language on reproductive health services contained within 
the Senate bill--than any other legislation in my career.
  I am grateful for the opportunity to be a part of this momentous 
reform and urge my colleagues to remember that today we will make a 
lasting difference in people's lives. Today we change the overall 
health of our Nation.
  Mr. LEVIN. I yield to the gentleman from Minnesota for a unanimous 
consent request.
  Mr. ELLISON. I rise in support of universal health care.
  Mr. Speaker, there was a time in our country's past that the 
enactment of a comprehensive civil rights law was deemed merely a 
dream.
  There was a time in our country's past that enactment of Social 
Security to guarantee the retirement security of our seniors was deemed 
merely a dream.
  There was a time in our country's past that enactment of the Medicare 
law to guarantee the health care for our nation's senior was deemed 
merely a dream.
  We now take all three--civil rights, retirement security for our 
seniors and health security--for granted in our society.
  They are all assumed as a given and as a right in our society.
  Well, Mr. Speaker, I believe when we leave this chamber tonight after 
passing this health care bill, we will forget how hard it was to pass 
this bill. And in another generation, our grandchildren will also 
assume that universal health care is a right and a given in any modern 
society.
  Mr. Speaker, tonight marks the beginning of the dream of universal 
health care becoming a reality in our society.
  It is an important beginning--
  When 40,500 uninsured Fifth District residents will have access 
health care coverage to health insurance.

[[Page 4151]]

  When 9,700 Fifth District residents with pre-existing conditions can 
no longer be denied coverage.
  When 57,000 Fifth District young adults can obtain coverage on their 
parents' insurance plans.
  When insurance coverage for 358,000 Fifth District residents is 
improved--and when the cost of uncompensated care for hospitals and 
other health care providers is reduced by $101 million--that is 
positive change.
  And when thirty-two million more Americans have health insurance it 
is a good beginning. At the same time, when $1.3 trillion in deficit 
spending (accumulated over the past eight years) is reduced, it is a 
good start.
  I look forward to enthusiastically casting my ``yes'' vote tonight 
for this historic legislation.
  Mr. LEVIN. I yield to the gentlelady from California for a unanimous 
consent request.
  Ms. RICHARDSON. I rise in support of this health care reform 
legislation.
  Mr. Speaker, I rise today in strong support of H.R. 4872, the 
Reconciliation Act of 2010, because this bill is good for seniors, good 
for women, good for small businesses, and good for all Americans. Today 
we have the opportunity to take a historic vote that will forever 
change the face, health, and life of America for the better. H.R. 4872 
will provide access to affordable, quality health care for over 30 
million Americans and will reign in the ever-escalating costs of health 
care. Today, history will be made and a legacy left behind for 
generations to come. 435 Members who represent over 300 million people 
will be remembered for beginning to fulfill the promise all Americans 
were pledged, the unalienable rights to life, liberty and the pursuit 
of happiness which adequate healthcare embodies.
  For the people I represent in the 37th District of California, H.R. 
4872 will improve coverage for 299,000 residents who already have 
insurance. It will give tax credits and other assistance to up to 
146,000 families and 15,100 small businesses to help them afford 
coverage. H.R. 4872 will improve Medicare for 63,000 beneficiaries in 
my district, including closing the donut hole for them. This 
legislation will extend coverage to 92,500 uninsured residents of the 
37th District and will guarantee that 17,500 residents with preexisting 
conditions can obtain the health insurance they need. H.R. 4872 will 
protect 1,100 families from bankruptcy due to unaffordable health care 
costs and will allow 59,000 young adults to obtain coverage on their 
parents' insurance plans. This bill will provide millions of dollars in 
new funding for 11 community health centers in my district. And 
finally, it will reduce the cost of uncompensated care for hospitals 
and other health care providers by $125 million annually.
  H.R. 4872 helps seniors by ensuring that they will not be forced out 
of Medicare, that their doctors will continue to care for Medicare 
patients because of increased payment levels, and that the prescription 
donut hole will be completely closed by 2020. H.R. 4872 helps women by 
eliminating the discriminatory gender rating system, making sure that 
insurance companies do not consider pregnancy grounds for denying 
coverage, and doing away with all preexisting conditions. H.R. 4872 
helps the uninsured by extending coverage to 95% percent of Americans. 
Furthermore, it increases access and choice for all Americans by 
providing $11 billion in new funding for community health centers, of 
which there are 11 in my district alone. Finally, H.R. 4872 helps small 
businesses by eliminating price and benefit discrimination, providing 
tax credits for up to 50 percent of the cost of insuring their 
employees, and giving them greater control over the spiraling costs of 
health care coverage.
  As I participated in countless debates, caucuses, and meetings over 
the past year, I knew that each step we took put us one step closer to 
what Theodore Roosevelt proposed in 1908 over 100 years ago: quality, 
affordable healthcare for all Americans. Our health care system up 
until now has not worked for most people, whether it be the physician 
as provider, the employer as payer, or the patient as recipient.
  Mr. Speaker, this bill provides American families with stability and 
peace of mind. Never again will they have to choose between their 
health and their livelihood. H.R. 4872 provides all American families 
with the possibility of better healthcare.
  It is time for us to move forward. H.R. 4872 is a new direction for 
this great country. I urge my colleagues to be a part of this historic 
heatlh care policy change, and to be part of the days ahead in which we 
will work to further strengthen it.

                              {time}  2030

  Mr. LEVIN. I now yield the balance of my time, 45 seconds, to the 
very distinguished gentlewoman from Florida (Ms. Wasserman Schultz).
  Ms. WASSERMAN SCHULTZ. Mr. Speaker, I rise today to cast my vote to 
end abusive insurance company practices that put doctors and patients 
in control of their health care.
  And when I do, I will cast it for the small business owner in my 
district whose health insurance premiums shot up more than 100 percent 
last year simply because one employee got sick. I will cast it for the 
135,000 people in my district who don't have health care coverage. On a 
personal note, I will cast it for the 2.5 million breast cancer 
survivors like me, who have a preexisting condition that make it next 
to impossible to obtain health insurance.
  Finally, I'll cast it for all of the moms in America with beautiful 
children like mine, but who don't have the security of health insurance 
and who die inside every time their child gets sick. Our current system 
is broken. It's un-American. The nightmare ends tonight.
  The SPEAKER pro tempore. All time has expired.
  The gentleman from California (Mr. George Miller) is recognized for 
15 minutes as a designee of the majority leader.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 2 minutes to 
the gentleman from New Jersey (Mr. Andrews), a member of the committee.
  Mr. ANDREWS. I thank my chairman for yielding.
  Mr. Speaker, the ladies and gentlemen of the House should respect our 
constituents who are against the bill, who are for the bill, and those 
who are undecided; but we should respect them enough to give them an 
accurate record of what's in the bill, and I think it's time for some 
accuracy.
  We have heard repeatedly tonight that there are cuts to Medicare in 
this bill. There is not one cut to not one beneficiary anywhere in this 
bill. Medicare benefits expand for prescription drugs and expand for 
preventive care. We heard someone say that the bill increases premiums 
for Americans.
  Section 1001 of the reconciliation bill says that for a family making 
$45,000 a year, if you look at their premiums, their copays and their 
deductibles, which is what real people have to do, the bill saves them 
$7,000 a year. We have heard that the special interest provisions, that 
I think are an abomination, are in the bill. They are not. If you read 
section 1201 of the reconciliation bill, it says goodbye to the so-
called Cornhusker kickback and other special interest provisions.
  We heard that there is taxpayer funding for abortions. Read section 
10,104 of the underlying bill. There isn't. We have heard that this is 
going to add to the deficit and the debt of the country. Don't listen 
to what the Democrats say. Don't listen to what the Republicans say. 
Listen to what the nonpartisan Congressional Budget Office says, which 
is this: the bill will save $138 billion off the deficit in the first 
10 years and $1.2 trillion off the deficit in the next 10 years.
  Finally, we hear the bill will kill jobs. When the Clinton economic 
plan was on this floor, a gentleman named Dick Armey, a leader of the 
anti-movement on this bill, said it would be ``a recipe for disaster.'' 
He was wrong. That bill created 23 million new jobs and we should 
vote----
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. GEORGE MILLER of California. I yield the gentleman 15 additional 
seconds.
  Mr. ANDREWS. Finally, I heard one of our colleagues say this bill 
will create a socialist utopia. No, Mr. Speaker, it won't. It will 
create a decent society that every man, woman, and child in this 
society and this country so richly deserves. Vote ``yes'' on this bill.
  The SPEAKER pro tempore. The gentleman from Minnesota (Mr. Kline) is 
recognized for 8 minutes as a designee of the minority leader.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield myself 1\1/2\ minutes.
  I came to Congress 7 years ago to do my part to make this country 
better. Every vote I cast and every policy I help shape must be judged 
by whether it achieves what my constituents sent

[[Page 4152]]

me here to accomplish. As each Member of this, the people's House, 
prepares to vote ``yea'' or ``nay'' tonight, we should all take a 
moment to remind ourselves of why we are here.
  Our job is to ensure American employers have the tools and the 
freedom they need to sustain jobs and create jobs. Instead, this bill 
will destroy jobs at a time when we need them the most.
  Our job is to ensure freedom, security and prosperity for future 
generations. Instead, this bill will be paid for by our children and 
our grandchildren and our great grandchildren. Our job is to legislate 
openly with integrity and fairness. Instead, this bill is full of back-
room deals negotiated behind closed doors.
  This bill is not what the American people want. They are imploring us 
to start over with reforms that will bring down health care costs while 
preserving the relationship between patients and their doctors. This is 
our last chance to stand up for the people who sent us here and display 
the courage to prove that we can do better.
  I reserve the balance of my time.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Connecticut (Mr. Courtney), a member of the committee.
  Mr. COURTNEY. Mr. Speaker, tonight we are going to answer a question 
which the tea party on the right to reformers on the left ask 
constantly, which is, Why can't the American people have access to the 
same type of benefit that Members of Congress have?
  It's a good question. Some of the most hysterical voices in 
opposition have access to a purchasing exchange through the Federal 
employee benefits plan that has comprehensive benefits, choice, no 
rescissions, no lifetime caps. And this bill is going to give the 
American people exactly what Members of Congress have. And in case 
there is any question about that, section 1312 will make sure that 
starting in 2014, Members of Congress have to use exactly the same 
purchasing exchange that the American people will have to use.
  No more haves and have-nots. No more tax-paying Americans who don't 
have health insurance, underwriting the health benefits of Members of 
Congress who would deny them access to quality, affordable health care. 
It is time to answer that question tonight in the affirmative by 
passing this legislation.
  Mr. KLINE of Minnesota. Mr. Speaker, I am pleased to yield 2 minutes 
to the gentleman from Georgia, the ranking member of the Health, 
Employment, Labor, and Pensions Subcommittee, Dr. Price.
  Mr. PRICE of Georgia. Mr. Speaker, health care decisions that we make 
for ourselves and for our families are some of the most important and 
personal in our lives. As a physician, early in my career of caring for 
tens of thousands of patients, I recognized that there were more folks 
in Washington who affected what I could do for and with my patients 
than anybody I ever met in residency or in medical school and that that 
was wrong.
  Health care, taking care of people, is a moral endeavor and should be 
grounded in principle. And if the principles that we hold dear for 
health care are applied to this debate and to this bill, the picture is 
not pretty: accessibility, being able to receive care; affordability, 
being able to afford care; quality, receiving the best care available; 
responsiveness, having a system that works for patients; and 
innovation, being certain that we have the newest and the best 
treatments and choices, patients being able to choose their physicians 
and how and where they are treated.
  All of these are harmed by this bill. All of these principles are 
violated. None of these principles are improved by the further 
intervention of the Federal Government.
  So you see, Mr. Speaker, mostly this is bad for patients, for all 
Americans. The trust that is necessary between caregiver and care 
receiver, between patients and their doctors, to believe that your 
health is not being undermined by the system will be permanently 
eroded, permanently damaged; and it is that trust that is the 
foundation of the morality of health care.
  So this is a sad day, yes, because there are so many wonderful and 
positive and patient-centered solutions that we could have enacted. You 
see, we trust patients and families. They trust government.
  As a physician, I know that when patients and their families and 
their doctors are not allowed to decide what they receive, we lose more 
than our health care system. We lose our morality. We lose our freedom.
  The positive vote, the patient-centered vote, the bipartisan vote on 
this bill is a ``no.''
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentlewoman 
from California (Ms. Woolsey), a member of the committee.
  Ms. WOOLSEY. Mr. Speaker, the whole Nation desperately needs health 
care reform, but no group of Americans needs it more than women who 
face discrimination and insult at the hand of the broken status quo 
every single day. We all know that the current system allows insurance 
companies to deny coverage based on preexisting conditions.
  But I wonder how many of my colleagues realize that essentially being 
a woman is a preexisting condition. Pregnancy, for example, or C-
sections, can be deemed preexisting conditions. Most unbelievable of 
all, insurance companies can legally turn their backs on women who 
suffered injuries due to domestic violence because that, too, can be 
defined as a preexisting condition. We should all be ashamed of a 
system that puts healthy insurance company profits ahead of healthy 
American women.
  This weekend, today, tonight, we will make history by passing a 
health care bill that will correct these injustices, and no longer will 
female be considered a preexisting condition.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time it is my pleasure 
to yield 2 minutes to the gentleman from Kentucky, the ranking member 
of the Higher Education, Lifelong Learning, and Competitiveness 
subcommittee, Mr. Guthrie.
  Mr. GUTHRIE. Mr. Speaker, I have always liked to describe the process 
I have seen in the last few weeks of trying to put a bill together like 
putting a puzzle together, but forcing pieces together and trying to 
make them fit. And in the end, the puzzle doesn't have a complete 
picture. And one of the pieces they are trying to make fit to keep this 
under $1 trillion, is what the score is; but what we are not mentioning 
is the incredible unfunded mandate that we were placing on our States.
  Just a couple of years ago I was a State senator. And tonight, State 
senators in Kentucky, my former colleagues, are meeting together to try 
to close a billion-dollar budget gap. And what does this bill do? This 
bill puts a $30 billion unfunded mandate by CBO estimates onto our 
States.
  To the south of Kentucky, Phil Bredesen, a very respected Democratic 
Governor of Tennessee, says this is the mother of all unfunded 
mandates. And just to the north of me in Indiana, Governor Mitch 
Daniels said a half a million more Hoosiers will be on Medicaid, 
costing the State taxpayers billions of dollars.
  It's going to cost my State, according to the Heritage Foundation, 
$303 million from 2014 to 2019. So that's what our next budget session-
mates will be budgeting for 2014. So the State legislators tonight who 
are hoping the economy will turn around, maybe there will be a light at 
the end of the tunnel, are now having to deal with the $303 million 
freight train that's the light at the end of that tunnel.
  But on top of that, this proposed bill also takes student loan money 
to finance this bill. The government has taken over the student loan 
business; they have lower interest rates. Instead of lowering the rate 
our students are going to be paying back on our interest, we are going 
to take part of that money and fund this bill on the backs of our 
students.
  Mr. Speaker, it's unfair to put these burdens on our States and on 
our students.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Arizona (Mr. Grijalva), a member of the committee.

[[Page 4153]]


  Mr. GRIJALVA. Mr. Speaker, today I rise in full support of the 
legislation to reform health care before us. It is, indeed, a historic 
opportunity for the American people to begin the necessary process of 
fixing a failing and broken health care system that is costly and 
denies basic health care to many, to 48 million Americans in this 
country.
  It is also a tremendous building block for the care of people in this 
country in the future and to begin to rein in the greed of private 
insurance companies that continue to raise premiums at the expense of 
the American people. This legislation has very good aspects in it. One 
of them is, finally, after 10 years of neglect by a Republican majority 
and administration, Indian health care is part of this legislation, and 
this health care brings necessary and increased resources to Indian 
Country.
  We begin to deal with health disparities in this legislation, which 
we have not done in the past. I am proud to support this legislation. 
It is not just a step forward; it is a historic leap into bringing to 
the American people a necessary reality, which is health care.
  The SPEAKER pro tempore. The time of the gentleman has expired.

                              {time}  2045

  Mr. KLINE of Minnesota. Mr. Speaker, could I inquire as to the time?
  The SPEAKER pro tempore. The gentleman from California has 9\3/4\ 
minutes remaining. The gentleman from Minnesota has 3 minutes 
remaining.
  Mr. KLINE of Minnesota. Mr. Speaker, then at this time I am pleased 
to yield 1 minute to the gentlewoman from Illinois, a senior member of 
the Education and Labor Committee, Mrs. Biggert.
  Mrs. BIGGERT. Mr. Speaker, I rise today deeply troubled, not just by 
this bill, but by the historic opportunity this body has squandered. We 
had so long to get this right, so many chances to take a step back and 
listen, really listen, to what the American people were asking us.
  Instead, true leadership was cast aside in favor of backroom deals, 
partisan games, and legislative gimmicks. The best intentions on both 
sides of the aisle never had a chance to turn good ideas into great 
policy, and we were left with a bill that is so poorly crafted that we 
are voting to overhaul it the same day it is going to the President.
  But the American people still have a choice. It is not between this 
partisan bill and nothing. We can work together to deliver the 
commonsense reforms that the American people want.
  Mr. Speaker, I know many colleagues have been struggling with this 
vote. I urge them to vote ``no'' and work with us to pass reforms we 
can all be proud of, that we can all vote for.
  Mr. Speaker, I vote ``no.''
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentlewoman 
from California (Ms. Shea-Porter).
  Ms. SHEA-PORTER. Tonight I vote for the middle class.
  I have heard the desperation of parents whose kids were kicked off 
their plan before they even had a job. This bill allows 30 percent of 
young Americans currently without coverage to stay on their parents' 
plans until age 26.
  I have listened as New Hampshire small business owners told me they 
were embarrassed they could no longer insure faithful employees. This 
bill is their remedy.
  I heard those who lost homes because they got sick or hurt, lost 
their insurance, and then could not pay medical bills. I listened as 
hospitals discussed the uninsured's costs to New Hampshire taxpayers. 
Here is the cure.
  For the late Donald Long of Raymond, who told me he paid $500 for 
prescriptions every 3 months because of the doughnut hole, thank you. I 
heard you and all seniors.
  I heard Sandra Gagnon of Manchester, who has a chronically ill 
daughter. Now, no more preexisting exclusions.
  For the families in New Hampshire and across America, I vote ``yes'' 
for you.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield myself the balance of my 
time.
  The SPEAKER pro tempore. The gentleman is recognized for 2 minutes.
  Mr. KLINE of Minnesota. Mr. Speaker, earlier this month President 
Obama said, ``Everything there is to say about health care has been 
said, and just about everyone has said it.''
  Perhaps he is right. Perhaps everyone in Washington has said all 
there is to say. The lines have been drawn, and the number of undecided 
votes is dwindling. But perhaps it is time for Washington to stop 
talking and start listening.
  I am listening to the calls coming into my office, 13-1 against this 
legislation. I am listening to residents of Minnesota's Second 
Congressional District, who told me during a town hall last week 72 
percent of them are opposed to this bill. I am listening to small 
business owners in my State and around this Nation who are paralyzed by 
the fear of new mandates, job-killing taxes, crushing Federal deficits, 
and more government control.
  I am listening to the thousands of citizens who traveled to our 
Nation's capital this weekend to tell us in no uncertain terms they 
want us to kill the bill. I am listening, and what I am hearing is the 
American people shouting ``stop.''
  They want us to start over. They want health care reform we can 
afford. They want reform that will bring down costs without sacrificing 
quality or personal freedom. Mr. Speaker, they want us to say ``no'' to 
this bill today so we can come back and do better tomorrow.
  There is no question that there are Members in this body, Republicans 
and Democrats, who are ready to go to work on a much improved bill.
  The die has not yet been cast. It is not too late. I urge my 
colleagues: Listen to the American people. Vote ``no.'' Vote ``no.''
  I yield back the balance of my time.
  Mr. GEORGE MILLER of California. I recognize the gentlewoman from 
Nevada (Ms. Titus), a member of the committee, for 1 minute.
  Ms. TITUS. For over 1 year, I have listened to the voices of District 
3 and heard heartbreaking stories of children denied coverage because 
of a preexisting condition, small business owners who can't afford to 
insure their employees, and single moms who have lost their jobs and 
their insurance. They are the reasons I am voting for reform.
  In District 3 alone, reform will improve coverage for more than 
600,000 people. It will strengthen Medicare for 120,000 seniors and 
close the prescription drug doughnut hole. It will create health care 
tax breaks for over 200,000 families and 17,000 small businesses, and 
lets 72,000 young adults stay on their parents' policy.
  Insurance companies and others opposed to reform have spent over $1.3 
million in southern Nevada, but I won't be intimidated. Today, as I 
have always done, I am standing up for what I believe is in the best 
interest of my constituents. As has been said, it is the price of 
leadership to do the thing you believe has to be done at the time it 
must be done. Now is the time to get it done and pass health care 
reform.
  The SPEAKER pro tempore (Mr. Pastor of Arizona). The gentleman from 
Wisconsin (Mr. Ryan) is recognized for 10 minutes as a designee of the 
minority leader.
  Mr. RYAN of Wisconsin. I reserve the balance of my time.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Texas (Mr. Hinojosa), the Chair of the Higher Ed Subcommittee.
  Mr. HINOJOSA. Mr. Speaker, I rise today in full support of this 
reconciliation legislation, to say that we have an extraordinary 
opportunity today to improve the quality of life for millions of 
Americans, for the 32 million children and families who are uninsured, 
and for students and workers who dream of pursuing higher education and 
acquiring the skills needed to access 21st century jobs.
  As subcommittee chair for Higher Education, I am proud to say that 
today Congress will invest billions of dollars to increase 
accessibility and affordability in higher education for our Nation's 
students and workers. This landmark legislation provides $36 billion in 
Pell Grant scholarships over 10 years. It provides $2 billion of moneys 
for our Nation's community colleges, and $2.55 billion for our 
minority-serving institutions of higher learning, including HSIs and 
HBCUs. By moving to

[[Page 4154]]

the Federal Government's direct loan program, we will put the best 
interests of students first and make college loans more reliable and 
affordable for students and families.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Massachusetts (Mr. Tierney), a member of the committee.
  Mr. TIERNEY. Mr. Speaker, today is an opportunity for this body to 
stand up for middle class families and small businesses.
  Today, by passing this bill, no family will have to worry that their 
20-something-year-old child will have a serious condition and not be 
covered or ever be refused coverage in their lifetime due to a 
preexisting condition. Insurance companies will no longer be able to 
limit coverage annually or over a lifetime just when serious conditions 
require care. They won't be able to rescind coverage in the middle of 
cancer or diabetes care, and they will have to spend a reasonable 
portion of premium dollars on actual health services.
  We will be able to see our seniors affording both their groceries and 
their prescription medicines because we will close the so-called 
doughnut hole in their current coverage, and we will extend the life of 
Medicare for 9 years even as we improve its coverage.
  Small business employers and employees will be better able to afford 
health care and will pay less in administrative costs while having the 
choices large companies and Federal employees have now.
  All this, Mr. Speaker, and we will be making the largest pay-down on 
the Federal deficit in quite some time, reducing our debt by over $1 
trillion in the next two decades.
  No bill is perfect, but this bill is an enormous improvement of the 
status quo.


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. The Speaker would remind Members to heed the 
gavel at the expiration of their time.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield for the 
purposes of a unanimous consent request to the gentlewoman from the 
District of Columbia (Ms. Norton).
  Ms. NORTON. For the tax-paying residents of the District of Columbia, 
I rise in strong support of the health care reform bill before us 
today.
  Mr. Speaker, if I could cast a vote on behalf of the residents of the 
District of Columbia, on final passage of the health care bill before 
us today, I would cast a critical ``aye.'' Unfortunately, however, the 
D.C. Voting Rights Act, like most bills this year, is in line behind 
health care reform. Fortunately for me, however, the most important 
point of contribution to a bill is usually not when the work is done, 
and all that needs to be done is to register your vote for the 
majority. The most critical point in this legislation was when it was 
being crafted. I believe that the many hours I have put into the health 
care bill to ensure that it served D.C. residents have been more than 
worth it. For example, beyond the many benefits for all Americans in 
the bill, D.C. will be relieved of the $50 million it has generously 
used to fund its D.C. Health Alliance for people who do not qualify for 
Medicaid, but cannot afford health insurance, a cost seldom picked up 
by other states.
  Mr. Speaker, this bill specifically benefits my constituents in many 
ways, particularly the following:
  For the 62 percent of D.C. residents who already have private health 
insurance, but are facing soaring insurance costs and could be dropped 
at the whim of an insurance company, the bill will reign in insurance 
costs by restricting administrative expenses, profits, and overhead; 
prohibit insurance companies from denying coverage based on pre-
existing conditions; prohibit annual and lifetime benefit caps; and 
prohibit insurance companies from dropping coverage when a person 
becomes sick.
  For the 134,000 uninsured families and 17,300 small businesses, the 
bill will provide tax credits to buy affordable insurance at group 
rates through the new health insurance exchanges that will be 
established, or for individuals with incomes below 133 percent of the 
poverty line, through expansion of Medicaid.
  For the 75,000 seniors receiving Medicare, the bill will add free 
preventative and wellness care, improve primary, coordinated, and 
nursing home care, and provide a $250 rebate this year and 50 percent 
discounts on brand name drugs beginning next year to the 3,300 seniors 
who have fallen through the donut hole and are forced to pay the full 
cost of prescription drugs, while closing the hole within 10 years.
  For 67,000 young adults in the District, the bill will allow them to 
stay on their parents' plan until age 26 and allow them to purchase 
affordable policies until age 30.
  For the 5,600 D.C. individuals with pre-existing conditions, the bill 
will ensure they are not denied affordable coverage.
  Families who purchase insurance through the health insurance exchange 
or are insured by small businesses will no longer face bankruptcy due 
to health care costs not covered by insurance, because the bill will 
cap out-of-pocket costs at $6,200 for individuals and $12,400 for 
families.
  For District of Columbia health care providers, the bill will provide 
up to $54.6 million for 42 D.C. community health centers, and will 
reduce the burden on uncompensated care by $69 million at the 
District's hospitals and other health care facilities.
  I am particularly pleased about the benefits that will be available 
to my constituents as soon as the bill is signed. For individuals, 
there will be coverage for early retirees, 55-64; coverage for young 
adults up to age 26 on parents' policies; preventative care for those 
receiving Medicare and for others, now under private plans; first steps 
to close the donut hole, coverage for residents with pre-existing 
conditions; and tax credits for small business employees. For many of 
my constituents, the elimination of abuses will be the most important 
parts of the bill, including no more cancellation of policies when 
residents get sick; no discrimination against children with preexisting 
conditions; no lifetime coverage limits; no annual limits on new plans; 
and requiring 80 percent of premiums for individuals and small groups, 
and 85 percent of large plan premiums, to be spent on the insured. 
Other critical provisions that will benefit many D.C. residents are the 
funds to double the number of patients the city's 42 community health 
centers can accommodate, and funding for training more primary care 
doctors.
  The SPEAKER pro tempore. The gentleman will be charged time.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield for the 
purposes of a unanimous consent request to the gentlewoman from 
California (Ms. Zoe Lofgren).
  Ms. ZOE LOFGREN of California. Mr. Speaker, I rise in support of the 
bill.
  I'm proud to stand on the floor of the House of Representatives today 
to cast my yes vote for this historic bill. I vote yes for the nearly 
50,000 currently uninsured residents of the 16th California 
Congressional District who will now be eligible for health insurance. I 
vote yes for the 6,000 seniors in my district who will no longer be 
subject to the donut hole in Medicare Part D. I vote yes for the 55,000 
young adults in the 16th District who will now be able to extend their 
coverage under their parent's existing insurance. I vote yes for the 
roughly 15,000 small businesses in the 16th District who will be able 
to extend coverage to their employees because of the tax credits in 
this bill. I vote yes for the 800 families in the 16th District who 
every year are forced to file for bankruptcy due to medical bills. I 
vote yes because this legislation will reduce the deficit by $130 
billion over the next 10 years and by some $1.3 trillion over the 
second decade. Simply put, I vote yes because it is the right thing to 
do and because my constituents overwhelmingly demand it.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield for the 
purposes of a unanimous consent request to the gentleman from 
California (Mr. Schiff).
  Mr. SCHIFF. Mr. Speaker, I rise in support of this historic health 
care reform legislation.
  Two years ago, during a telephone townhall with my constituents, one 
of my neighbors in Burbank told me that her young daughter had become 
ill. Our children played together in preschool, and they lived just a 
few doors down. When her daughter became sick, they were able to get 
her the health care she needed through a program called Healthy 
Families. She was now, thankfully, all better.
  But now, my constituent told me, she herself was ill. She and her 
husband were both self-employed and could not afford health insurance, 
and she was scared to death to get her illness treated at the emergency 
room. Her question to me that night was: ``Is there any hope for 
families like mine?''
  The answer tonight is ``yes.'' There is now hope for millions of 
self-employed Americans who cannot afford health care, and millions 
more who are small business people struggling to provide health care 
for themselves and their employees. And there is hope for millions of 
others who have pre-existing conditions and cannot obtain health 
insurance. And

[[Page 4155]]

for millions of seniors who have fallen through the donut hole in their 
prescription drug coverage. Because tonight's bill will address the 
needs of each and every one of these Americans who are struggling to 
afford the coverage they have, or find health insurance when they are 
without.
  Our health insurance system is intrinsically linked to our Nation's 
and California's economic recovery. There are now more than 30 million 
American citizens who do not have health insurance coverage, and every 
day, 14,000 Americans lose their coverage. In fact, Californians are 
more likely to be uninsured than most Americans--over 7 million 
Californians are uninsured this year.
  Millions of Americans now receive their care at the emergency room, 
and millions more must make the difficult choice of whether to pay 
their medical bills or pay their mortgage because they cannot afford to 
do both; two-thirds of all bankruptcies and half of all foreclosures 
are a result of a health care crisis in the family.
  This recession has highlighted wide and growing gaps in our health 
care system. Families lose their insurance coverage when a parent in 
the household becomes unemployed, and too many parents without 
employment are falling through those widening cracks--unable to afford 
COBRA, ineligible for public coverage, and precluded by high premiums 
and/or pre-existing conditions from obtaining private insurance.
  Collectively, as a Nation, we spend almost twice as much per person 
on health care as any other country, or about 17 percent of our gross 
domestic product, and this number is growing every year far faster than 
inflation.
  Tonight, I'm voting to pass legislation that will substantially 
reform the health insurance industry and practices, extend quality 
coverage to millions of Americans, and hold down national, public, and 
private health care costs. This bill will help provide stable coverage 
that cannot be taken away and won't be lost when you change jobs, and 
will provide additional insurance choices in an invigorated and 
competitive marketplace.
  In my district alone, this bill will provide tax credits and 
financial assistance to over 135,000 families and 15,000 small business 
owners in order to help them afford coverage, and extend coverage to 
80,000 uninsured residents. This bill will close the ``donut hole'' for 
94,000 seniors, and extend the life of Medicare. Further, we act 
tonight in a fiscally responsible manner, reducing the deficit by over 
$1.3 trillion during the next two decades.
  Tonight, we make it illegal to deny health coverage to the 15,000 
constituents in my district with pre-existing conditions. We ensure 
that the costs of health care won't threaten their family's finances, 
that their doctor is paid for making them well and not ordering 
unnecessary tests, and that their health care premiums are spent on 
actual care, not paying for paperwork and red tape.
  I have two young children, and I cannot imagine the dread that a 
parent must feel who has a sick child for whom they cannot provide 
care. That is an agony no parent should ever know. Not here. Not in 
America. I have had one steady guide through my years in Congress, and 
it is my two children. When they are old enough to know of my work in 
Congress, I want them to be proud of what their father did when he had 
a chance to serve this great Nation. And I believe they will be proud 
of me for casting my vote to provide health care for millions who do 
not have it, just as I am proud of the generation who went before and 
provided health care for millions of seniors when they had the courage 
to pass Medicare.
  I strongly believe that access to affordable, quality, stable health 
care is the key to a productive work force, small business innovation, 
and the economic as well as health security of our families and Nation, 
and I'm proud to vote for this bill.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield for the 
purposes of a unanimous consent request to the gentlewoman from 
California (Mrs. Davis).
  Mrs. DAVIS of California. Mr. Speaker, I rise in support of health 
care reform--finally.
  When people are asked why they chose their profession, so many say 
it's because they wanted to make a difference.
  We have the unique opportunity and honor to do just that.
  Passing healthcare reform will impact our constituents in almost all 
aspects of their lives.
  Good health is one of the most important things a person can have--
there is truth in the saying that it is more valuable than all the 
riches in the world.
  The bill we're passing isn't just about reducing sky-rocketing 
premiums or putting patients ahead of insurance companies--it's about 
the total outlay for families when it comes to providing for both basic 
and high risk care.
  Having affordable and certain health insurance translates not only to 
better health care but to better financial security so people can save 
money and use it for the betterment of their families.
  It means Americans can take the job they want, not just the job with 
healthcare.
  And it means they can strike out on their own and start the new 
businesses that spur our economy.
  We are making a difference as we do this for the American people.
  I truly appreciate my constituents whether they are for or against 
this measure, and I thank all of them for sharing their stories with 
me.
  Mr. RYAN of Wisconsin. Mr. Speaker, I yield 2 minutes to the vice 
ranking member of the Budget Committee, the gentleman from Texas (Mr. 
Hensarling).
  Mr. HENSARLING. Mr. Speaker, the vote we take tonight very well may 
unalterably change the role of government in a society whose most 
cherished birthright is that of personal freedom.
  There are so many reasons to oppose this legislation. Taxpayer-funded 
abortions, the sleazy backroom deals that brought us the Cornhusker 
kickback, the Louisiana purchase, the pharmaceutical payoff, one-half 
trillion dollars in tax increases on an economy where millions have 
lost their jobs and can still find no gainful employment.
  As a member of the House Budget Committee, let me give you one more: 
We can't afford it. Our government can't even pay for the promises it 
has made current generations, much less future generations.
  After giving us the largest deficits in American history, after 
proposing to triple the national debt in the next 10 years, Democrats 
today want to add $2.6 trillion of new spending to the Federal budget, 
costing every household $22,000. That is more money to borrow from the 
Chinese, more bills to send to our children and grandchildren. Mr. 
Speaker, you cannot improve the health care of a Nation by bankrupting 
its children.
  I have seen the Democrats' Congressional Budget Office letter about 
cost. Garbage in, garbage out. When you put facts in, you get facts 
out. My Congressional Budget Office letter says the program will add to 
the deficit.
  But even more than cost, this is really a debate about who will 
control the health care resources of this Nation and who will control 
the health care decisions of our families. If we pass this bill, we 
will wake up one day only to find that when our loved ones become ill, 
they will wait weeks, perhaps months, to see a mediocre doctor of the 
government's choosing, only to be told by that same doctor that he 
cannot help because his treatment must be limited by the government 
protocol.
  In America, we must never confuse the social safety net with the 
slippery slope to socialism.
  When it comes to the health care of my family, when it comes to the 
health care of my country, I reject the hubris and arrogance of 
government social engineering, and I embrace the affordability and 
portability that comes by preserving the liberties of the American 
people.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from New York (Mr. Bishop), a member of the committee.
  Mr. BISHOP of New York. Mr. Speaker, over the course of this long and 
passionate debate, amidst the angry and at times even hateful rhetoric, 
amidst the misinformation of scare tactics, there exists one simple 
truth, and that truth is that the current system is unsustainable. It 
is a system that threatens to bankrupt the Federal Government and every 
other level of government, and it is a system that is already 
bankrupting businesses, families and individuals.
  Those who stand in the way of reform are protecting this system. To 
do nothing is to ensure a future of ever escalating rates, slashed 
benefits, and, most tragically, illness and disease that go untreated.
  The bill before us is not perfect, but it does enable us to begin to 
take action on the most pressing issues that affect the hardworking 
families we represent.

[[Page 4156]]

  In my district alone, 24,000 uninsured individuals will get coverage, 
97,000 families will receive tax credits to defray the cost of 
coverage, 20,000 businesses will receive tax credits to provide their 
employees with coverage, and 49,000 young adults will be able to remain 
on their parents' policies.
  On behalf of these people and the millions like them, let's pass this 
bill tonight.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentlewoman 
from Wisconsin (Ms. Moore).
  Ms. MOORE of Wisconsin. As a member of the Budget Committee, I have 
had the opportunity to hear the most specious, inaccurate, 
contradictory, and downright laughable arguments against health 
insurance reform.
  Take, for example, the argument that we need to start over because 
the Congressional Budget Office score had been done 17 months earlier 
and now was old and stale. And, oh, by the way, the debate has dragged 
on for 17 months. Yet, the minority simultaneously complains that 
somehow we are hurrying and ramming the bill through.
  Once the CBO score was recalculated demonstrating phenomenal deficit 
reduction, the complaint became that the CBO is playing number tricks. 
Of course, the minority trusts CBO when the scores work for them.
  The minority's plan is to allow insurance premiums to rise 
unregulated by government intervention, let a family of four's premiums 
double every decade, and end Medicare as we know it.

                              {time}  2100

  If the health insurance reform debate wasn't so serious, these 
arguments would be laughable.
  Mr. RYAN of Wisconsin. At this time, Mr. Speaker, I'd like to yield 2 
minutes to gentleman from New Jersey (Mr. Garrett).
  Mr. GARRETT of New Jersey. Mr. Speaker, I rise in strong opposition 
to this bill for two very important reasons. First, I believe that this 
bill fundamentally violates the U.S. Constitution and it will be found 
unconstitutional once it gets its way through the courts.
  While Congress is given the power under the Constitution to regulate 
interstate activity, never before have we had to be required to 
purchase a private product--government approved--as a price of U.S. 
citizenship. This moves far beyond regulating economic activity into 
the realm of regulating inactivity.
  If we allow that Congress has this authority under the Constitution, 
then there is no limit whatsoever of Washington's ability to 
micromanage our lives. In the future, if Congress feels our car 
industry needs a boost again, they can require us all, once again, to 
purchase a car from GM. That is not exactly what our Founding Fathers 
had in mind.
  Thirty-seven States have already filed legislation to challenge this 
bill. Two States have already passed laws threatening lawsuits if this 
bill passes tonight. One State lawmaker has pointed out that that's 
two-thirds of the States of this great country, enough States to change 
the Constitution.
  In addition, there's another reason it should be rejected. It's 
because it puts us hopelessly in debt. Democrats assert that their bill 
would reduce the deficit over the next 10 years, and more thereafter. 
Utter nonsense. As the ranking member has repeatedly pointed out, there 
are budget gimmicks in here and double counting galore. Your very own 
actuaries from the HHS, what do they say about that? They say that the 
bill is ``unrealistic.'' Furthermore, it would ``jeopardize access to 
care'' for senior citizens.
  So, then, what can we count on after this massive program passes and 
we have $2.5 trillion in additional spending at an 8 percent growth 
rate? Think about it. We can't even pay our own debts today. Please, 
don't add another unconstitutional, economic burden to this and future 
generations.
  Vote down this bill.
  Mr. GEORGE MILLER of California. I yield to the gentleman from Texas 
(Mr. Gene Green) for the purpose of a unanimous consent request.
  Mr. GENE GREEN of Texas. Mr. Speaker, I rise in support of H.R. 3590 
and also H.R. 4872.
  Mr. Speaker, I rise in strong support of H.R. 3590, the Patient 
Protection and Affordable Care Act and H.R. 4872, the Reconciliation 
Act of 2010.
  We are in desperate need of health care reform in the 29th District 
in Texas. We have one of the highest number of uninsured individuals in 
our country where nearly 43 percent of the residents are uninsured. If 
enacted, H.R. 3590 and H.R. 4872 would provide insurance coverage to 95 
percent of all Americans and for 223,500 currently uninsured residents 
in the 29th district.
  It will also improve the employer based coverage for 217,000 
residents in my district. Also, approximately 177,000 families and 
14.600 small businesses will receive tax credits and other assistance 
to help them afford health insurance coverage under these bills.
  The legislation before us today will give all individuals the ability 
to access quality affordable health insurance, and approximately 34,500 
residents in our district will no longer be denied coverage for 
preexisting conditions and their coverage cannot be capped or dropped 
when they get sick.
  The legislation before us today also ensures no more co-pays for 
preventive care, no more yearly caps on what the insurance company will 
cover, and provides premium subsidies for those who need them.
  We will also improve Medicare benefits for 56,000 seniors in our 
district by closing the Part D donut hole over time and immediately 
provide seniors who are in the donut hole with a $250 credit in 2010.
  The legislation also improves seniors' benefits under Medicare by 
providing free preventive and wellness care, improving primary and 
coordinated care, and enhancing nursing home care. The bill also 
strengthens the Medicare Trust Fund, extending its solvency from 2017 
to 2026.
  H.R. 3590 and H.R. 4872 will rein in rising health costs for American 
families and small businesses--introducing competition that will drive 
premiums down, capping out-of-pocket spending.
  According to the Congressional Budget Office, CBO, this legislation 
is fully paid for by eliminating waste, fraud, abuse, and excessive 
profits for private insurers. Nationwide, these health reform bills 
will reduce the deficit by over $130 billion over the next 10 years and 
by about $1.2 trillion over the second decade.
  Texas will also benefit from the legislation before us today. The 
Texas Department of Health and Human Services, TDHHS, released 
estimates that H.R. 3590 and H.R. 4872 will cost the State $24 billion 
over the next 10 years--this is inaccurate.
  These estimates are incorrect because they do not include the federal 
expansion and 100 percent contribution of Medicaid payments until 2018. 
Right now Texas accounts for 7 percent of Medicaid spending nationally. 
If those levels stay the same after the State-based exchanges are set 
up, the cost to the State of Texas would be $1.4 billion and not $24 
billion. Additionally, the bill will reduce the expenses related to 
uncompensated care in our State by $15 million annually.
  Currently, there are 5.9 million uninsured individuals in Texas. 
Under H.R. 3590 and H.R. 4872 nearly all of those individuals will have 
health insurance and most of it will be funded at federal expense--not 
at the expense of Texas. In fact, given the size of the State it is 
entirely possible that Texas will receive the largest amount of federal 
investment of any other State and create many new jobs in the health 
care sector.
  The time for health reform has come. Health insurance premiums are 
growing three times faster than wages and last year, more than half of 
Americans postponed medical care or skipped their medications because 
they couldn't afford it.
  I urge my colleagues to vote in favor of the legislation today not 
only for my constituents, but for all Americans.
  Mr. GEORGE MILLER of California. I yield for the purpose of a 
unanimous consent request to the gentleman from Missouri (Mr. 
Carnahan).
  Mr. CARNAHAN. Mr. Speaker, I rise in support of this important health 
care package for America.
  Mr. Speaker, today, history was made.
  Today was for Sharon, from St. Louis, whose husband has Parkinson's 
Disease, and whose medication costs quadruple every May, when he falls 
into the donut hole.
  Today was for Mary, whose has lived in fear of losing her coverage 
because she knows her son will be refused coverage because of his 
preexisting condition.
  Today was for Michelle, who can't afford health coverage for the 
employees in her small bookstore.

[[Page 4157]]

  Today was for Stacy, whose grandmother died because she didn't have 
access to preventative care, leaving her family devastated and her 
grandfather broke from medical debt.
  An American President once said, ``There has long been a need to 
assure every American financial access to high quality health care. As 
medical costs go up, that need grows more pressing. Now, for the first 
time, we have not just the need but the will to get this job done.''
  That President was Richard Nixon in 1974.
  Indeed, the effort to make sure quality, affordable health care is 
available to all Americans dates back nearly 100 years, when Teddy 
Roosevelt called for reform, a call echoed by Democratic and Republican 
Presidents alike--Eisenhower, Kennedy, Nixon--and even Missouri's own 
Harry S. Truman.
  Today, we have finally fulfilled this century-old mission.
  No longer will older Americans face financial ruin because they can't 
afford to purchase life-saving medicine.
  No longer will parents fear that their children will be denied 
coverage because they have a preexisting condition.
  No longer will small businesses be forced to choose between health 
care or hiring additional employees.
  And no longer will people die, in the wealthiest country in the 
world, simply because they cannot afford care.
  That all ends today, with the passage of this bill to stop the 
insurance companies from denying care to people who are sick and rein 
in rising costs to make health care more affordable for families and 
small businesses, giving everyone access to the kind of health care 
choices available to Members of Congress.
  It's about time. We have a healthier America. A healthier America 
means a stronger, more productive, more competitive America.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentleman from New York (Mr. Tonko).
  Mr. TONKO. Today we answer the clarion call from the American people 
to fix our Nation's broken health care system. Today is the day we 
deliver on that promise with a vote as historic as the creation of 
Social Security and Medicare.
  Today I will cast my vote in favor of putting the control back into 
the hands of American families and small businesses and their doctors. 
No longer will insurance companies be able to hold people hostage by 
raising rates and abuse sick people by dropping and denying coverage. 
Small businesses will no longer see their premiums skyrocket and will 
not have to make the painful decision to stop offering health insurance 
to their employees because the costs have climbed too high.
  Indeed, this bill is about freedom. Every American will now have the 
freedom from control of insurance companies and their record profits 
and will have the freedom to access the care they need, when they need 
it. Our seniors will have the freedom to enjoy Medicare for years to 
come, and they will have the freedom from worrying about the cost of 
their prescription drugs.
  The bottom line for me, Mr. Speaker, is whether the people in the 
capital region of New York will be better off with these reforms, and 
my answer is yes. Absolutely, yes.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield to the 
gentlewoman from Texas (Ms. Jackson Lee) for the purpose of a unanimous 
consent request.
  Ms. JACKSON LEE of Texas. In the name of my mother, Ivalita Jackson, 
I affirmatively support this bill for all of America.
  Mr. Speaker, I have the great honor and privilege to rise in strong 
support of H.R. 4872, ``The Health Care & Education Affordability Act 
of 2010,'' a bill that will make health care affordable for the middle 
class, provide security for seniors, and guarantee access to health 
insurance coverage for the uninsured--while responsibly reducing the 
federal deficit over the next decade and beyond. I would like to thank 
President Obama and the leadership in the House and Senate for guiding 
us through this journey.
  Mr. Speaker, when I stand here today and reflect upon what we are 
about to embark upon, I cannot help but think of some of the last words 
that the Great Senator Edward Kennedy shared in his letter to President 
Obama. The Senator said, ``And so because of your (Obama's) vision and 
resolve, I came to believe that soon, very soon, affordable health 
coverage will be available to all, in an America where the state of a 
family's health will never again depend on the amount of a family's 
wealth. And while I will not see the victory, I was able to look 
forward and know that we will--yes, we will--fulfill the promise of 
health care in America as a right and not a privilege. Well, Senator, 
your life's work shall today be proven to not be in vain.
  Though it has been a long journey to get to this place and many have 
suggested that we need to start over and wait until some other time in 
the future to address the health care crisis. In the words of the great 
civil rights leader, Dr. Martin Luther King, Jr., that ``we have also 
come to this hollowed spot to remind America of the fierce urgency of 
now.'' We cannot wait. We will not wait any longer to provide the 
citizens of this great Nation access to affordable, quality health 
care.
  Today when we pass this bill, it will be a historic day not only for 
tens of millions of uninsured Americans, but also for our great Nation. 
As Speaker Pelosi has reiterated, we as Members of Congress, are 
``humbled to stand here at a time when we can associate ourselves with 
the work of those who passed Social Security, those who passed 
Medicare, and now we will pass health care reform.''
  Many parallels exist between that time in history and today. 
Throughout this journey, we have listened to a parade of Republicans 
warn that this bill will bring the downfall of American society, of the 
American way of life. This, however, is not the first time that the 
Republicans have been on the wrong side of history. In an interview in 
1975, David L. Kopelman, who played a prominent role in the early 
administration of the Medicare Program, remarked that his colleagues 
were often criticized by Republicans. ``Communist,'' he recalled, ``was 
the designation all too liberally applied to anyone with a progressive 
idea. Well, after all, when we went around making contact with 
employers in those early years that was the designation not delicately 
applied by many, if not most of them, to the social security program. 
It must be some communist scheme foisted on the American people.'' Alf 
Landon, the Republican candidate for President in 1936, even campaigned 
on the fact that not a dollar in social security benefits would ever be 
paid.
  Mr. Speaker, unfortunately, such ad hominem attacks are as prevalent 
as ever. The Republicans want you to believe that our country is 
descending into an abyss of socialism, but nothing could be further 
from the truth. Today, I am proud to support a bill that is distinctly 
American. We the people, Thomas Jefferson wrote in the Declaration of 
Independence are endowed ``with certain unalienable Rights that among 
these are Life, Liberty and the pursuit of Happiness.--That to secure 
these rights, Governments are instituted among Men, deriving their just 
powers from the consent of the governed . . .'' I believe that it is no 
coincidence that life is listed first--for without it, the Founders 
realized, no other rights can be realized. Over many years, the 
millions of Americans who could not access medical services were denied 
their right to life--a life with access to quality and affordable 
health care.
  Let me set the record straight, this bill is good for the American 
people and will go a long way to ensuring access to quality and 
affordable care to those millions of Americans who for far too long 
have been left out of the health care equation. This health insurance 
reform legislation (the Senate bill as improved by the Reconciliation 
Bill) that the House is considering today will not only ensure that 
Americans have access to quality, affordable health care, but will also 
significantly reduce long term health care costs. The non-partisan 
Congressional Budget Office (CBO) has determined that it will provide 
coverage to 32 million more people, or more than 95% percent of 
Americans, while lowering health care costs over the long term. This 
historic legislation will reduce the deficit by $138 billion over the 
next ten years, with $1.2 trillion in additional deficit reduction in 
the following 10 years
  In the words of the great President John F. Kennedy, ``the voters 
selected us, in short, because they had confidence in our judgment and 
our ability to exercise that judgment from a position where we could 
determine what were their own best interest, as a part of the nation's 
interest.''
  Mr. Speaker, while my colleagues on the other side of the aisle claim 
that this bill will harm Americans, nothing could be further from the 
truth. This bill will:
  Make health insurance affordable for middle class and small 
businesses--including the largest middle class tax cuts for health care 
in history--reducing premiums and out-of-pocket costs.
  Strengthen consumer protections and rein in insurance company abuses.
  Give millions of Americans the same types of private insurance 
choices that members of

[[Page 4158]]

Congress will have--through a new competitive health insurance market 
that keeps costs down.
  Hold insurance companies accountable to keep premiums down and 
prevent denials of care and coverage, including for pre-existing 
conditions.
  Improve Medicare benefits with lower prescription drug costs for 
those in the ``donut hole''; it also provides better chronic care, free 
preventive care, and nearly a decade more of solvency for Medicare.
  As President Obama says, ``we must act now'' and put American 
families and small businesses, not health insurance companies, in 
control of their own health care. This bill will do exactly that. Many 
of my colleagues on the other side of the aisle claim that we are 
passing a bill that nobody really knows what is in it. Well, Mr. 
Speaker, let me just take a minute to list a few things that are in the 
bill.
  The bill provides quality, affordable health care for all Americans 
that: a
  Bars insurance companies from discriminating based on pre-existing 
conditions, health status, and gender.
  Provides Americans with better coverage and the information they need 
to make informed decisions about their health insurance.
  Creates health insurance exchanges--competitive marketplaces where 
individuals and small business can buy affordable health care coverage 
in a manner similar to that of big businesses today.
  Offers premium tax credits and cost-sharing assistance to low and 
middle income Americans, providing families and small businesses with 
the largest tax cut for health care in history.
  Insures access to immediate relief for uninsured Americans with pre-
existing conditions on the brink of medical bankruptcy.
  Creates a reinsurance program in support of employers who offer 
retirees age 55-64 health coverage.
  Invests substantially in community health centers to expand access to 
health care in communities where it is needed most.
  Empowers the Department of Health and Human Services and state 
insurance commissioners to conduct annual reviews of new plans 
demanding unjustified, egregious premium increases.
  Expands eligibility for Medicaid to include all non-elderly Americans 
with income below 133 percent of the Federal Poverty Level (FPL).
  Replaces the so-called ``Cornhusker'' deal with fair assistance for 
all states to help cover the costs of these new Medicaid populations.
  Maintains current funding levels for the Children's Health Insurance 
Program (CHIP) for an additional two years, through fiscal year 2015.
  Increases payments to primary care doctors in Medicaid.
  The bill improves medicare by:
  Adding at least nine years to the solvency of the Medicare Hospital 
Insurance trust fund;
  Filling the Medicare prescription drug donut hole. In 2010, Medicare 
beneficiaries who go into the donut hole will receive a $250 rebate. 
After that they will receive a pharmaceutical manufacturers' 50 percent 
discount on brand-name drugs, increasing to a 75% discount on brand-
name and generic drugs to close the donut hole by 2020;
  Providing new, free annual wellness visits, and eliminates out-of-
pocket copayments for preventive benefits under Medicare, such as 
cancer and diabetes screenings;
  Providing better chronic care, with doctors collaborating to provide 
patient-centered care for the 80 percent of older Americans who have at 
least one chronic medical condition like high blood pressure or 
diabetes;
  Improving Medicare payments for primary care which will protect 
access to these vital services;
  Reduces overpayments to private Medicare Advantage plans. Medicare 
currently overpays private plans by an average of 14 percent. This 
legislation reins in those overpayments to ensure a fair payment system 
that rewards quality;
  Encouraging reimbursing health care providers on the basis of value, 
not volume. The bill includes a number of proposals to move away from 
the ``a la carte'' Medicare fee-for-service system toward paying for 
quality and value while reducing costs for America's seniors.
  The bill prevents chronic disease and improves public health that 
promotes preventive health care at all ages and improves public health 
activities that help Americans live healthy lives and retrain the 
growth of health care costs over time. The legislation eliminates cost-
sharing for recommended preventive care, provides individuals with the 
information they need to make healthy decisions, improves education on 
disease prevention and public health, and invests in a national 
prevention and public health strategy.
  The bill improves health care workforce by making key investments in 
training doctors and nurses and other health care providers. Currently, 
65 million Americans live in communities where they cannot easily 
access a primary care provider. An additional 16,500 practitioners are 
required to meet their needs. The legislation addresses shortages in 
primary care and other areas of practice by making necessary 
investments in our Nation's health care workforce. Specifically, it 
will invest in scholarship and loan repayment programs through the 
National Health Service Corps to expand the health care workforce. The 
bill also includes incentives for primary care practitioners and for 
providers to practice in underserved areas.
  The bill provides for transparency and program integrity by providing 
consumers with information about physician ownership of hospitals and 
medical equipment companies, as well as nursing home ownership and 
other characteristics. The bill also includes provisions that will 
crack down on fraud, waste, and abuse in Medicare, Medicaid, SCHIP and 
private insurance. It establishes a private, non-profit entity to 
identify priorities in patient-centered outcomes research that will 
provide doctors with information on how to best treat patients and end 
wasteful overspending.
  This bill also improves access to innovative medical therapies and 
establishes a regulatory pathway for FDA approval of biosimilar 
versions of previously licensed biological products.
  The bill also provides community living assistance services and 
support that makes long-term support and services more affordable for 
millions of Americans by providing a lifetime cash benefit that will 
help people with severe disabilities remain in their homes and 
communities. CLASS is a voluntary, self-funded, insurance program 
provided through the workplace. For those whose employers participate, 
affordable premiums will be paid through payroll deductions. 
Participation by workers is entirely voluntary. The Congressional 
Budget Office confirms that the program, which has been revised from 
earlier versions, is actuarially sound.
  The bill provides revenue provisions that:
  Reduce the deficit in the next ten years and beyond. The bill is 
fully paid for with revenue provisions that focus on paying for reform 
within the health care system.
  Tighten current health tax incentives, collect industry fees, 
institute modest excise taxes, and slightly increase the Medicare 
Hospital Insurance (HI) tax for individuals who earn more than $200,000 
and couples who earn more than $250,000. The taxable base of the HI tax 
is also broadened by including net investment income. The HI tax 
increases will not only help fund health care reform, but, when 
combined with other provisions in the bill, will also extend the 
solvency of the Medicare Trust Fund by at least nine years to 2026.
  Include a fee on insurance companies that sell high cost health 
insurance plans. The fee is designed to generate smarter, more cost-
effective health coverage choices. The reconciliation bill delays this 
new fee until 2018 so that plans have time to implement reform and 
begin to save from its efficiencies.
  Change health care tax incentives by increasing penalties on 
nonqualified distributions from HSAs, capping FSA contributions, and 
standardizing the definition of qualified medical expenses. The 
industry fees and excise taxes reflect responsible contributions from 
health care stakeholders who will benefit from the expanded coverage of 
millions of additional Americans under health care reform. The bill 
also assesses a small excise tax on indoor tanning services.
  In total, the revenue provisions in the bill represent a balanced, 
responsible package of proposals that bend the health care cost curve 
by putting downward pressure on health spending, close unintended tax 
loopholes, and promote tax compliance.
  Mr. Speaker, who among us can say with sincerity that the quality of 
one's life, which certainly includes one's health, is not heavily 
dependent upon the access to quality, affordable health care. According 
to the National Academy of Sciences, Institute of Medicine, there is a 
``consistent and statistically significant relationship between health 
insurance coverage and health outcomes for adults. These factors, in 
turn, improve the likelihood of disease screening and early detection, 
the management of chronic illness, and the treatment of acute 
conditions . . . .'' Recently, a study published in the American 
Journal of Public Health by researchers at Harvard University Medical 
School concluded that nearly 45,000 excess deaths of Americans can be 
linked each year to lack of health insurance.
  According to the U.S. Census Bureau, 27 million Americans live 
without health insurance, and an additional 1.1 million part-time 
workers lost their health insurance in 2008.

[[Page 4159]]

Implementing this legislation will instantly improve the life 
expectancy of millions of Americans of all ages. It is impossible to 
put a price on that. When we talk about the right to healthcare, we are 
actually talking about the right to life--a life that includes access 
to quality health care.
  The bill contributes to reducing health disparities. Minority 
communities are particularly vulnerable to being left uninsured and 
underinsured. In our current system, most people do not choose to be 
uninsured but, instead, are priced out of insurance. These people 
cannot, as free market proponents often argue, ``Pull themselves up by 
their bootstraps.'' Instead, they and their families are too often 
cyclically and systemically trapped in their economic situation. As a 
result, minority communities suffer grave health disparities that would 
otherwise be limited but for lack of access to affordable and quality 
care.
  According to a 2003 National Health Disparities Report released by 
the Agency for Research Quality and Care:
  Minorities are more likely to be diagnosed with late-stage breast 
cancer and colorectal cancer compared with whites.
  Patients of lower socioeconomic position are less likely to receive 
recommended diabetic services and more likely to be hospitalized for 
diabetes and its complications.
  When hospitalized for acute myocardial infarction, Hispanics are less 
likely to receive optimal care.
  Many racial and ethnic minorities and persons of lower socioeconomic 
position are more likely to die from HIV. Minorities also account for a 
disproportionate share of new AIDS cases.
  The use of physical restraints in nursing homes is higher among 
Hispanics and Asian/Pacific Islanders compared with non-Hispanic 
whites.
  Blacks and poorer patients have higher rates of avoidable hospital 
admissions (i.e., hospitalizations for health conditions that, in the 
presence of comprehensive primary care, rarely require 
hospitalization).
  This historic bill is particularly important for minorities and 
women--who have gone without health care coverage for too long. In 
2007, only 49 percent of African-Americans in comparison to 66 percent 
of non-Hispanic whites used employer-sponsored health insurance, 
according to the Department of Health and Human Services. During the 
same year, 19.5 percent of African-Americans in comparison to 10.4 
percent of non-Hispanic whites were uninsured.
  Hispanics have the highest uninsured rates of any racial or ethnic 
group within the United States. In 2004, the Centers for Disease 
Control and Prevention reported that private insurance coverage among 
Hispanic subgroups varied as follows: 39.1 percent of Mexicans, 47.3 
percent of Puerto Ricans, 57.9 percent of Cubans, and 45.1 percent of 
other Hispanic and Latino groups.
  Health care reform also is critical to ensure that women have access 
to affordable health care coverage. An estimated 64 million women do 
not have adequate health insurance coverage. About 1.7 million women 
have lost their health insurance coverage since the beginning of the 
economic downturn. Nearly two-thirds lost coverage because of their 
spouse's job loss. And nearly 39 percent of all low-income women lack 
health insurance coverage. Women also are more likely to deplete their 
savings accounts paying medical bills than men because they are more 
likely to be poor. This bill gives women access to the health care that 
they need and deserve.
  Passage of this bill will be a critical first step in helping to 
reduce such health disparities. This bill will:
  1. Lower costs for minority families and preventive care for better 
health. Racial and ethnic minorities are often less likely to receive 
preventive care. Vietnamese women, for example, are half as likely to 
receive a pap smear, and twice as likely to die from cervical cancer as 
are Whites. Obesity rates are also high among certain minority groups. 
By ensuring all Americans have access to preventive care and by 
investing in public health, health insurance reform will work to create 
a system that prevents illness and disease instead of just treating it 
when it's too late and costs more.
  2. Provide greater choices and more affordable choices and 
competition. African Americans, Hispanics, and Asians are all more 
likely to need a referral in order to see a specialist and they are 
less likely to get coverage for seeing a doctor outside of the 
insurance network. Health insurance reform will create a health 
insurance exchange so you can compare prices and health plans and 
decide which quality affordable option is right for you and your 
family. It will include a competitive public option that increases 
choices and holds private insurers accountable.
  3. Allow for quality, affordable health care for minorities and 
eliminates discrimination in obtaining health insurance. Health 
insurance reform will prevent any insurance company from denying 
coverage based on a person's medical history, including genetic 
discrimination which can disproportionately hurt minority populations.
  4. Make health care accessible to everyone. African Americans, 
Hispanics, and Native Americans are roughly twice as likely to be 
uninsured as the rest of the population. By providing health insurance 
choices to all Americans and providing premium assistance to make it 
affordable, health insurance reform will significantly reduce 
disparities in accessing high-quality health care.
  5. Control chronic disease. Nearly half of African Americans suffer 
from a chronic disease, compared with 40 percent of the general 
population. Chronic illness is growing in other minority communities as 
well. Health insurance reform includes a number of programs to prevent 
and control chronic disease, including incentives to provide medical 
homes and chronic disease management pilots in Medicare.
  6. Promote primary care. By providing health insurance choices 
through a health insurance exchange and investing in the primary care 
workforce (including scholarships and grants to increase diversity in 
health professions), health reform will make sure that all Americans 
have access to a primary care doctor so they stay healthier, longer. It 
will also strengthen the system of safety-net hospitals and community 
health centers to ensure high-quality, accessible care.
  Health reform legislation will require any health care program to 
report on race, ethnicity, gender, and socioeconomic status in order to 
better understand health disparities, and devote funding to addressing 
these issues.
  The uninsured in Texas. The people of my home state of Texas, in 
particular, with 6 million uninsured persons, and 26 percent uninsured 
in my district, the 18th Congressional District, have been hit 
especially hard when it comes to lack of access to quality, affordable 
care.
  And just what causes such a massive loss of health care coverage? Job 
layoffs are partially to blame especially in the face of the economic 
downturn. Yet, we know that the uninsured problems existed way before 
the devastating recession. Many Americans continue to be forced from 
their health care plans due to decisions by insurance companies to put 
profits over people. Policy cancellations rather than paying for 
expensive yet necessary medical treatment is just one of the many 
techniques used by large insurance companies to rack up huge profits 
annually.
  According to the latest figures analyzing the profits of health 
insurance companies, 10 of the country's largest publicly traded health 
insurance companies enjoyed a rise in profits of 428 percent, from 2000 
to 2007. From filings with the U.S. Securities and Exchange Commission, 
it was revealed that in 2007, these insurance companies alone generated 
$12.9 billion in profit. That same year, the chief executive officers 
at these companies collected combined total compensation packages of 
$118.6 million--an average of $11.9 million each. That is 468 times 
more than what an average American worker made that year.
  Since 2007, there has been a 10 percent increase in the uninsured 
rate in Texas alone. Today, 6,240,000 Texans are without even basic 
health insurance. And this broken health insurance system has cost the 
Texas economy dearly. This year, Texas lost $30 billion in productivity 
as a result of its millions of uninsured residents.
  Those in our state who are blessed to have insurance coverage have in 
some ways been losers as well. Specifically, the average Texan family 
pays insurance premiums of over $1000 a month. This figure is set to 
nearly double to $1920.75 per month by 2019, that is, unless we succeed 
in passing health care reform legislation. Today, when we pass this 
bill, the people of Texas and all over this nation become winners.
  We know that many of our colleagues in this body do not want to 
reform the health care system and are on the side of the big insurance 
companies. We choose to stand on the side of the Americans who need our 
help. President Franklin D. Roosevelt said it best when he said, ``the 
test of our progress is not whether we add more to the abundance of 
those who have much; it is whether we provide enough for those who have 
little.''
  While the state-wide numbers are shocking, on the local level, the 
health care figures are even worse. The 18th Congressional District and 
the rest of Houston, account for 1.1 million of the state's uninsured 
residents. Nationally, more than 15 percent are uninsured. In Texas 
it's nearly 24 percent. Here in Harris

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County, it's 30 percent, according to state figures, the highest rate 
among the nation's top 10 metropolitan areas.
  So how do the million plus Houston residents without insurance 
company get health care--emergency rooms of course. Emergency rooms 
have become the health care providers of last resort for well over 100 
million Americans annually. Over a 10 year period from 1994 to 2004, ER 
visits on a national level saw an 18 percent jump, according to the 
Centers for Disease Control and Prevention. The Texas Hospital 
Association reports that ERs in the state experienced a 33 percent 
increase; in the Houston area, it was more than 50 percent. During this 
ten year period, the number of hospital emergency departments dropped 
by more than 12 percent nationally.
  Emergency rooms in Houston hospitals are routinely overcrowded and 
overused as throngs flock seeking care for ailments that may range from 
a heart attack or gunshot wound to an ear infection or toothache. 
Ambulances pile up outside emergency rooms before unloading their  
patients. It's reported that a wait of an hour or two to move a patient 
from the ambulance to the ER is common in Houston. David Persse, the 
Houston Fire Department's medical director, confided with a reporter 
recently that the record wait to unload an ambulance at Houston area 
hospital is six hours.
  Ben Taub, the Houston area's pre-eminent trauma care facility, has 
seen the brunt of the problem. In a recent USA Today article, one Ben 
Taub nurse reported arriving to work one morning to find ER patients 
waiting to be seen who arrived the day before, over 24 hours earlier. 
ER overcrowding is so bad in the Houston area, that patients have 
called 911 from one ER to get to another, according to one report. When 
we pass this bill tonight, these Americans who have been flocking to 
emergency rooms for primary care will have another option--affordable 
and accessible health care.
  The benefits to the 18th congressional district: In my district, the 
health care bill will:
  Improve coverage for 279,000 residents with health insurance.
  Give tax credits and other assistance to up to 186,000 families and 
14,600 small businesses to help them afford coverage.
  Improve Medicare for 70,000 beneficiaries, including closing the 
doughnut hole.
  Extend coverage to 180,500 uninsured residents.
  Guarantee that 27,600 residents with pre-existing conditions can 
obtain coverage.
  Protect 500 families from bankruptcy due to unaffordable health care 
costs.
  Allow 62,000 young adults to obtain coverage on their parents' 
insurance plans.
  Provide millions of dollars in new funding for 20 community health 
centers.
  Reduce the cost of uncompensated care for hospitals and other health 
care providers by $27 million annually.
  As we reach this great milestone today, I am still reminded of the 
unfinished work that is left to do. We must ensure that physician-owned 
hospitals are allowed to maintain operations that allow them to serve 
the most vulnerable and underserved communities. I am committed to 
working with the Speaker's office and Senatorial leadership now that we 
are taking the first step in stemming the rising tide of the many 
uninsured. The protection of physician-owned hospitals is an issue of 
national interest. We have a lot of work to do as we move toward the 
Senate and to the conference. I was gratified to meet with the Speaker 
to discuss the continued protection of the very viable physician-owned 
hospitals and believe that we have a real opportunity to address this 
issue in the very near future.
  I offered three amendments that would have gone a long way to save 
physician-owned hospitals. My first amendment would have preserved 
physician-owned facilities that have a greater percentage of Medicaid 
inpatient admissions than the state average in operation and allows 
them to expand. My second amendment is extremely critical for minority 
communities and high poverty. This amendment would prevent physician 
safety-net hospitals from closing and preserves critical care access 
for impoverished communities and the disabled.
  My third amendment, supported by Physician Hospital Association of 
America, would effectively prevent the closure of 230 existing 
hospitals, save $2.9 billion in total payroll, $608 million in federal 
taxes, $3.5 billion in trade payables, and preserves 62,000 full- and 
part-time jobs by striking all language that prohibits grandfathered 
facilities from expanding.
  During the ongoing healthcare debate, discussions about physician 
ownership of hospitals have ignored the positive impact these 
facilities have had on minority communities and minority physicians. 
Physician-owned general acute care hospitals, who have unprecedented 
amounts of minority owners, have allowed Hispanic, Black, and Asian 
Americans to enter into the field of hospital ownership. The largest 
physician-owned hospital, Doctors Hospital at Renaissance, is over 50 
percent minority owned.
  To help my colleagues understand what is at stake, I would like to 
highlight some of these success stories:
  In Houston, St. Joseph's Hospital, a full-service general acute care 
center, is the only hospital that serves one of the most income-
challenged and African-American sections of the city. Within the last 
few years, a for-profit corporation abandoned this hospital and the 
surrounding community. Physician ownership provided an avenue for it to 
stay open and prevent a critical loss for the neighborhood.
  In South Texas, out-of-state corporations forced over 700,000 Texans 
to travel more than 250 miles to receive life-saving medical 
procedures. Decisions not to offer needed services by out-of-state 
healthcare conglomerates and the lack of public or county hospitals, 
left patients with two options: go without or to transfer to another 
facility up to 350 miles away. Income-challenged families who could not 
afford the travel were placed in great peril. Physician ownership 
enabled a group of local doctors to open a new hospital with advanced 
medical capabilities that reduced the need for travel to seek care. 
Doctors Hospital at Renaissance, a 506-bed premiere general acute care 
center, now provides some of the best care in the Nation and 
consistently has been recognized by Thompson Reuters as a Top 100 
Hospital in the Nation.
  In the Chinatown section of Los Angeles, California, the Pacific 
Alliance Medical Center (PAMC), a 142-bed full-service hospital, has 
been the community's main hospital for 140 years. This facility was 
purchased by a group of physicians 20 years ago after the existing 
hospital board planned to close and demolish the facility. Physician 
ownership once again provided an avenue for the hospital to stay open 
and serve an at-risk community.
  I will continue to work on behalf of these Americans and to to save 
physician-owned hospitals that are currently treating patients or under 
significant development, to ensure that Americans can continue to 
receive healthcare at the local hospitals they have come to depend 
upon. Physician-owned hospitals take care of patients covered by 
Medicare and Medicaid, as well as patients who are uninsured or cannot 
pay for their care. They also provide emergency departments access for 
their communities. At a time when we are concerned about the shortage 
of hospital beds in the face of epidemics like the swine flu, my 
amendment to this landmark bill will make sure no hospital is forced to 
shut its doors or turn away Medicare or Medicaid patients. The benefits 
that will come from our efforts to protect physician-owned hospitals 
are far reaching and will prevent any further losses to local 
economies. Not only do physician hospitals deliver high-quality medical 
care to the patients they serve, they also provide much needed jobs, 
pay taxes, and generate significant economic activity for local 
businesses and communities. Existing physician-owned hospitals employ 
approximately 51,700 individuals, have over 27,000 physicians on staff, 
pay approximately $2,421,579,312 in payroll taxes and $512,889,516 in 
other federal taxes, and have approximately $1.9 billion in trade 
payables. Hospitals currently under development would employ 
approximately 21,700 more individuals. With approximately 50 physician-
owned hospitals, Texas leads the Nation in the number of physician-
owned hospitals. The Texas economy could lose more than $2.3 billion 
and more than 22,000 jobs.
  In my district, the 18th Congressional District of Houston, Texas, 
St. Joseph Medical Center is a general acute-care hospital that treats 
all patients. In fact, its 40 percent Medicaid patient population is 
double the average hospital's patient population in the entire State of 
Texas and is one of the highest in the country. St. Joseph's was 
operated by the Sisters of Charity for many years until it was 
scheduled to be closed because the order could no longer support it. 
The hospital was offered to for-profit and not-for-profit hospital 
systems but no one would accept responsibility for operating St. 
Joseph's. A plan was developed to convert the hospital into 
condominiums. I refused to allow that to happen. It was only at that 
point that the physicians who had practiced there for many years came 
together to buy the hospital to save it from closing.
  St. Joseph's takes care of patients covered by Medicare and Medicaid, 
as well as patients who are uninsured or cannot pay for their care. The 
emergency departments of many physician-owned ``specialty hospitals'' 
have been criticized for not having a true emergency department. St. 
Joseph's has a department which is open 24 hours per day, 7 days

[[Page 4161]]

per week, providing an access point for patients in need of emergency 
services. In fact, St. Joseph's admissions through the emergency 
department are double the State average;
  St. Luke's hospital in Houston, which is church-owned, has three new 
facilities under development; the nonprofit religious mission has the 
controlling interest. One full-service hospital has one phase already 
operating, but would be under the growth restrictions; the hospital 
cannot be completed if the new restrictions apply. The hospital brought 
approximately 300 new jobs to the community; and
  Baylor Health Care System, based in Dallas, has found that their 
partnership with physicians has increased measurable quality, increased 
patient satisfaction, and decreased the cost in the delivery of their 
excellent care. This joint venture model has produced a heart hospital 
that has the lowest readmission rate in the entire United States. And 
yet this bill would deny Baylor Health Care System the right to add a 
single operating room or procedure room to meet its community's need. 
During the moratorium on physician-owned hospitals some years ago, 
Baylor wanted to add a badly needed OB/GYN service at its Frisco, 
Texas, hospital. This service is a money-losing service, but there was 
no such service within many miles for those people--Baylor fulfilled 
the need. It was prohibited from adding this service simply because the 
hospital had physicians holding a minority of the ownership of the 
hospital. After the moratorium was lifted, the service was added and is 
currently working at its capacity.
  Mr. Speaker, can we imagine witnessing an impact, of no patient beds, 
6- to 8-hour waiting times, to extend even to 10-hour waiting times, 
turning emergency patients away at the door? Can we imagine the 
dramatic case, when patients are not able to have access to quality 
care? This is true of the most serious trauma, of the most serious 
medical cases. Physician-owned hospitals serve in many cases at least 
40 percent of the city's population. I don't just mean the city's 
population. We are discussing a population that is between 500,000, 
which is the indigenous population, and the population of 1.5 million 
that's in the city every day.
  When a hospital downsizes in a particular city, it extends beyond the 
boundaries of that city, and in doing so, with this hospital being 
downsized, it's impacting all of the hospitals, not only in the city, 
but those hospitals in nearby jurisdictions. We're seeing the epicenter 
of a catastrophic event, and unless we realize the importance of this 
one medical facility, but look at it not from the perspective that it 
serves this city, but we have to realize that it serves the world. It 
serves the Nation. At the very least, it serves the Nation; at the very 
most, it most serves the world. So when you start looking at it from 
those perspectives, then it becomes more than just a problem of 
Houston, Texas, but a problem of this Nation. And it should be 
addressed in that manner.
  If we do not work closely together to look deeper at this issue, we 
will face a number of medical facility closures that is a disservice to 
the American people. So, we see that there seems to be a phasing-back 
or cutback in all of the major services, but the most important of 
those services, which directly affect the health and well-being of the 
citizens, or again, those 1.5 million people who visit and work in the 
city every day. So, we hear the same thing time and time again, even 
though individuals are saying that the patient caseload can be handled 
by the surrounding hospitals. You need but step into any emergency room 
on any day, at any time, and just see the impact of this one hospital 
being downsized. The impact will reach out throughout the city of 
Houston.
  Mr. Speaker, through all the debate, name-calling, threats, and fear-
mongering, we will once again be on the right side of history and put 
the American people first. In the midst of it all, some of my 
colleagues have been called derogatory names, including racial 
epitjets; have been spat on and have been threatened that there will be 
blood in the streets. But there is something that I must say to my 
fellow Americans as we stand on the threshold of the door that opens up 
to access to quality and affordable care and, in turn, a better quality 
of life for all Americans. Heeding one of this country's greatest 
leaders in history, Dr, Martin Luther King, Jr., I urge us to remember 
that ``in the process of gaining [life, liberty, and the pursuit of 
life], we must not be guilty of wrongful deeds. Let us not seek to 
satisfy our thirst for freedom by drinking from the cup of bitterness 
and hatred. We must forever conduct our struggle on the high plane of 
dignity and discipline . . . we must rise to the majestic heights of 
meeting physical force with soul force.
  Mr. Speaker, I urge my colleagues and I to stand strong, support this 
bill on behalf of all Americans.
  Mr. GEORGE MILLER of California. I yield myself the balance of my 
time.
  Mr. Speaker, I rise in support of this truly historic and great 
legislation that addresses two of America's greatest troubles: the 
crushing cost and high obstacles of obtaining both quality health care 
and a quality college education. Our Nation has suffered from our 
longstanding failure to make health care and college accessible to all 
American people. Americans have waited a long time for health insurance 
reform, nearly a hundred years.
  Today, Congress and President Obama will deliver on a central 
promise, a dream deferred, and on a crucial demand. Because of this 
legislation, for the first time in America's history, never again will 
Americans have to worry about losing their health insurance if they 
change or lose their job. The insurance companies will not be able to 
jack up premiums or deny coverage because of preexisting conditions. 
They will not be able to drop people's coverage when they get sick--
when they need it the most. Our reforms will improve the lives of every 
single American, those with insurance today and those without.
  We're also pairing this historic health reform with another 
opportunity that cannot be missed, the chance to make the single 
largest investment in college affordability ever, at no cost to the 
taxpayers. We're going to take $61 billion of wasteful subsidies that 
have gone to the banks and student lenders and instead recycle that 
money on behalf of students, their families who are trying to pay for 
education, to make that education more affordable and pay down the 
deficit of this country.
  We now face a very simple choice. We can side with America's families 
and make health insurance and college more affordable and accessible 
while creating millions of jobs and reducing the deficit, or we can 
side with the insurance companies and the banks. It's a very simple 
choice. One is to stand with the families and the students of this 
country, to stand with our future, to modernize our education system, 
to make it more affordable, and to modernize and make more affordable 
our health care system.
  I suggest all my colleagues should stand with American families in 
this country.
  Mr. Speaker, I rise in support of this truly historic legislation 
that addresses two of America's greatest troubles--the crushing costs 
and high obstacles of obtaining both quality health care and a college 
education.
  Our Nation and its economy have suffered from our longstanding 
failure to make health care and college accessible and affordable to 
all of the American people.
  Americans have waited a long time for health insurance reform--nearly 
100 years.
  Today, Congress and President Obama will deliver on a central 
promise, on a dream deferred, on a crucial demand.
  Because of this legislation, for the first time in America's history, 
never again will Americans have to worry about losing their health 
insurance if they change or lose their job.
  Insurance companies will not be able to jack up premiums or deny 
coverage because of a pre-existing condition.
  They will not be able to drop people's coverage when they get sick--
and need it most.
  There is no other plan on the table today that offers Americans these 
vital assurances.
  Our reforms will improve the lives of every single American--those 
with insurance today and those without it.
  They will improve our economy by reducing the deficit, creating up to 
4 million jobs over the next decade, and unshackling innovative 
business decisions from crippling health insurance costs.
  Our legislation offers families and employees of small businesses 
access to choices of affordable health plans; security and control over 
their health care; vital federal and state consumer protections; 
accountability for insurance companies; and coverage for 32 million 
Americans who don't have insurance today.
  This legislation also intends to lessen and eventually eliminate the 
loopholes and inconsistencies in our current system. More specifically, 
it seeks to begin the creation of a joint national and state health 
care system. Currently, we have a fragmented and unfair set of rules.
  If you are poor you may or may not be covered by Medicaid and your 
benefits will vary depending on the state you live in.

[[Page 4162]]

  If you are employed, you may or may not be offered benefits by your 
employer and those benefits vary from employer to employer. As 
providers continue to increase costs year after year, insurers, 
employers and states have been unable to effectively negotiate and 
responded by cutting benefits and increasing costs for individuals and 
families.
  This bill will help change this unsustainable and unfair dynamic. 
Under this legislation, every American will have an obligation and an 
opportunity to enjoy meaningful health benefits. The Secretary of 
Health and Human Services will establish an essential benefits package 
that will provide a basic but comprehensive set of benefits for all 
Americans. Although existing employer plans are not required to provide 
this level of benefits, it is our hope that employers will meet or 
exceed this standard. However, the bill does end a wide series of 
abuses that all health plans, including employer provided plans, must 
comply with.
  These include an end to all pre-existing condition exclusions, limits 
on waiting periods for coverage, and elimination of annual and lifetime 
caps on benefits.
  In order to make health care more affordable for workers and 
employers, the bill establishes exchanges that will negotiate with 
insurers to offer health coverage to individuals in a given area or 
state. These government-sponsored exchanges will establish a level 
playing field market place that will make health benefits fairer to all 
parties.
  Insurers will get organized access to large pools of individuals who 
are required to purchase insurance with lower income individuals 
receiving federal subsidies to afford essential benefits. Employers 
will be relieved of their current burdens of designing and negotiating 
for health benefits under this new health system. Employers will simply 
facilitate the enrollment and payroll deduction of their employees in 
exchange health plans with no other responsibilities. Employers may 
select a plan level to which any employer contribution will be limited, 
but employees are free to choose plans in that or a more favorable 
level.
  The health plans offered through the exchange are state licensed 
(with the exception of the national plans) and are not ERISA plans. 
States have full authority to protect their residents and enrolled 
individuals have state law rights and consumer protections. There is no 
federal preemption of any state law that does not prevent the 
application of any of the rights and responsibilities included in Title 
I of this bill.
  Small employers that choose to offer health coverage may be eligible 
for tax credits and cannot offer health benefits that discriminate in 
favor of highly compensated employees. For employers who use employee 
payroll and similar organizations (i.e. Professional Employee 
Organizations), I expect that the U.S. Department of Treasury will 
issue rules to make clear the circumstances by which the small employer 
may take the tax credit and satisfy the prohibition against 
discrimination.
  The bill contains an individual mandate to either obtain health 
insurance or pay a penalty. This provision is grounded in Congress's 
taxing power but is also necessary and proper--indeed, a critical 
linchpin--to the overall effort to reform the health care market and 
bring associated costs under control throughout interstate commerce. 
For example, without this requirement, some reforms may create the 
opportunity for moral hazards, such as the prohibition on pre-existing 
conditions.
  Without an individual mandate, individuals could wait to purchase 
health insurance until they are sick--thereby driving up insurance 
costs and undermining the bill's efforts to bring health care costs and 
costs to the broader economy under control. This requirement spreads 
risk to ensure lower costs for everyone, prevents adverse selection, 
helps end overpayment by the government and other consumers for the 
uninsured, and makes health care reform overall sustainable.
  I also would like to address a few other important provisions in the 
bill:
  I am pleased that the essential benefits in the Patient Protection 
and Affordable Care Act include rehabilitative and habilitative 
services and devices, as these benefits are of particular importance to 
people with disabilities and chronic conditions.
  The term ``rehabilitative and habilitative services'' includes items 
and services used to restore functional capacity, minimize limitations 
on physical and cognitive functions, and maintain or prevent 
deterioration of functioning. Such services also include training of 
individuals with mental and physical disabilities to enhance functional 
development.
  The term ``rehabilitative and habilitative devices'' includes durable 
medical equipment, prosthetics, orthotics, and related supplies. It is 
my understanding that the Patient Protection and Affordable Care Act 
requires the Secretary of Health and Human Services to develop, through 
regulation, standard definitions of many terms for purposes of 
comparing benefit categories from one private health plan to another. 
It is my expectation ``prosthetics, orthotics, and related supplies'' 
will be defined separately from ``durable medical equipment.'' I also 
expect that durable medical equipment will not be limited to ``in-
home'' use only.
  Pursuant to employer requests, this bill codifies the use of wellness 
programs. Wellness programs are proving to be an emerging area of 
health care reform that holds both great promise and potential for 
abuse. The Departments of HHS and Labor will need to issue regulations 
to assure that employer wellness programs meet established standards of 
medical treatment and patient protection. It is my understanding from 
discussions with my colleagues in both the House and Senate that the 
design and implementation of voluntary wellness programs, including the 
issuance of policies and procedures and the adoption of practices and 
methods of administration, shall not have the purpose or effect of 
mandating participation in such programs or punishing, denying, 
limiting or curtailing any rights, privileges, and protections under 
the Americans with Disabilities Act, the Genetic Information 
Nondiscrimination Act, the Health Insurance Portability and 
Accountability Act, the Family and Medical Leave Act, and Title VII of 
the Civil Rights Act of 1964.
  In order to ensure existing civil rights and privacy protections, 
regulations related to wellness programs promulgated by the Secretary 
of Health and Human Services should include standards and criteria 
developed and certified by the Attorney General, the Secretary of 
Labor, and the Equal Employment Opportunity Commission. I expect that 
nothing in the Patient Protection and Affordable Care Act shall limit 
the independent authority of the Attorney General, the Secretary of 
Labor, and the Equal Employment Opportunity Commission to issue 
regulations, interpretations, and guidance regarding the applicability 
of the Americans with Disabilities Act, the Genetic Information 
Nondiscrimination Act, the Health Insurance Portability and 
Accountability Act, the Family and Medical Leave Act, and Title VII of 
the Civil Rights Act of 1964 to the design and implementation of 
wellness programs. I urge the Department of Labor and other agencies to 
monitor and ensure that health plans properly comply with the standards 
established by this Act. I also urge the Congress to continue to review 
and revisit this developing area of health care.
  The Senate bill includes provisions that would provide for a ``level 
playing field'' between private health insurance issuers and a 
competing Consumer Operated and Oriented Plan (``CO-OP''), a community 
health insurance option, or a nationwide qualified health plan. These 
provisions would prevent unfair competition within a state where these 
plans compete.
  For example, if a CO-OP is established in New York State, it would 
have to be subject to all the same federal and state laws enumerated in 
these level playing field provisions as private health insurance 
issuers in New York State are. Or, for example, if a CO-OP were 
established in Florida and was exempted from a state law relating to 
licensure, private health insurance issuers in Florida would also have 
to be exempted from the same state law.
  The bill we are passing contains protections for employees who are 
retaliated against for reporting violations involving health insurance 
regulation and the operation of exchanges, and provides recourse for 
workers who are fired or otherwise discriminated against because they 
participate in the exchange and the employee receives a tax credit or a 
subsidy to purchase health insurance through an exchange. Under this 
legislation such employees can bring a complaint to and receive 
assistance from the Department of Labor.
  Section 2951 of H.R. 3590 makes an amendment to section 511 of Title 
V of the Social Security Act to require states to conduct statewide 
needs assessment and to coordinate such assessment with other 
appropriate assessments, and cross-references section 640(g)(1)(C) of 
the Head Start Act. This should not be interpreted to provide states 
with any new authority over Head Start grantees or entities applying 
for Head Start funds.
  Now, we're pairing these truly historic health insurance reforms with 
another opportunity that cannot be missed: The chance to make the 
single largest investment in college affordability ever--and at no cost 
to taxpayers.
  We are going to take tens of billions of dollars that for decades has 
gone to banks in the student loan program and instead give that money 
to students and to pay down the deficit.
  For decades, banks have enjoyed a sweetheart deal: They receive 
taxpayer money to make virtually risk-free loans to students.

[[Page 4163]]

  As we speak, the federal government is now funding 88 percent of all 
federal student loan volume.
  It has proven to be a more stable lender for students through shaky 
financial markets and a more cost-effective lender for taxpayers.
  Ending these subsidies is not a radical idea.
  President Clinton first identified these subsidies as wasteful in the 
1990s.
  President Bush eyed them in three of his budgets.
  And President Obama has correctly proposed ending this boondoggle 
once and for all by originating all loans through the federal direct 
lending program--saving taxpayers $61 billion over 10 years.
  And that's what our legislation accomplishes.
  Our reforms are good for students, taxpayers and American jobs.
  We will help low and middle-income students pay for college and 
invest in the support they need to graduate.
  We will be more responsible with taxpayer dollars by using $10 
billion of these savings for deficit reduction.
  And we will end the practice of banks shipping lending jobs offshore.
  This bill makes unprecedented investments to expand high-quality 
educational opportunities to all Americans. It invests in the Pell 
Grant scholarship award, strengthens Historically Black Colleges and 
Universities and minority serving institutions, and provides more 
resources to states for college access and completion efforts through 
the College Access Challenge Grant program.
  Further, these investments are paid for without increasing our 
nation's deficit, through key reforms in the federal student loan 
programs designed to provide a stronger, more reliable, and more 
efficient student loan system. The legislation directs $10 billion of 
the savings generated under this legislation to paying down the 
country's deficit.
  The education provisions of this legislation will convert all new 
federal student loans to the Direct Loan program starting in July 2010, 
saving $61 billion over the next 10 years. These changes will also 
upgrade the customer service borrowers receive when repaying their 
loans and promote jobs. The legislation will maintain jobs by 
maintaining a robust role for the private sector, allowing lenders and 
non-profits to get contracts with the Department of Education to 
service Direct Loans.
  These education provisions will convert all new federal student loans 
to the Direct Loan program starting in July 2010, saving $61 billion 
over the next 10 years. These changes will also upgrade the customer 
service borrowers receive when repaying their loans and promote jobs. 
The legislation will maintain jobs by maintaining a robust role for the 
private sector, allowing lenders and non-profits to get contracts with 
the Department of Education to service Direct Loans.
  The legislation significantly increases the federal Pell Grant award; 
the cornerstone of need-based federal student assistance since its 
creation in 1972. Investments in this program are essential to ensuring 
educational access and making college more affordable for students and 
families. Both the House and Senate authorizing and appropriating 
committees have made significant investments in increasing the maximum 
Pell Grant award in the past few years--32 percent since 2006. The 
investments in this legislation build on these commitments by indexing 
the maximum Pell Grant award to the Consumer Price Index beginning in 
the 2013-2014 academic year, to reach an estimated maximum of $5,975 in 
the 2017-2018 academic year.
  The legislation invests additional resources in the College Access 
Challenge Grant program created under the College Cost Reduction and 
Access Act of 2007 to assist states working in partnership with 
institutions of higher education, non-profit philanthropic 
organizations, and other organizations with experience in college 
access, to ensure that students have access to high-quality, affordable 
higher education.
  It is the intent of Congress that states receiving grants under the 
College Access Challenge Grant program should partner with entities, 
including guaranty agencies (including their non-profit subsidiaries), 
to provide financial literacy, delinquency and default aversion 
activities, and other loan counseling activities for borrowers.
  While this legislation seeks to ensure increased access and success 
for all students, we intend for the Secretary to work with states to 
address the unique access issues faced by underserved communities, 
including: low-income individuals, individuals with disabilities, 
homeless and foster care youth, disconnected youth, nontraditional 
students, members of groups that are traditionally underrepresented in 
higher education, individuals with limited English proficiency, 
veterans (including those just returning from active duty), and 
dislocated workers.
  The legislation also includes a continuation of funding for 
investments in Historically Black Colleges and Universities, Hispanic-
Serving Institutions, Tribal Colleges, Alaska and Hawaiian Native, 
Predominantly Black Institutions, institutions serving Asian American 
and Pacific Islanders, and institutions serving Native Americans, first 
made under the College Cost Reduction and Access Act of 2007, 
recognizing the critical role these institutions play in serving the 
nation's emerging majority populations.
  Concerning the servicing contracts with eligible not-for-profit 
servicers, this legislation recognizes that not-for-profit servicers 
play a unique and valuable role in helping students in their states 
succeed in postsecondary education and that students should continue to 
benefit from the assistance provided by not-for-profit servicers, 
including customer service, financial counseling, and college access 
and success programs.
  In addition, by including more high-quality servicers in the 
contracting process, competition will be increased thereby delivering 
better quality for student borrowers. Under the bill, not-for-profit 
servicers will be allocated a minimum of 100,000 borrower loan 
accounts. With sufficient loan volume and competitive servicing rates, 
eligible not-for-profit servicers can individually or collectively 
generate sufficient revenue to continue the valuable services they 
provide to borrowers. Because of the significant increase in loan 
volume as all federal loans are moved to the Direct Loan program, 
additional servicing capacity will be needed and is provided for 
through the contracts provision. I encourage the Secretary to implement 
these provisions so that many local not-for-profit servicers will 
continue to play a role in the student loan program.
  As more students become increasingly dependent on loans, the 
Department of Education must increasingly focus on the assistance, 
information, and repayment tools that assist students in successful 
loan repayment. When evaluating the resources and services available to 
student borrowers and schools under the Direct Loan program, I 
encourage the Secretary to use existing contracting authority to 
contract, when appropriate, with state-designated guaranty agencies for 
the delivery of services that increase student loan repayment and 
decrease default. Such agencies shall include those non-profit 
subsidiaries of guaranty agencies that were established, pursuant to 
State law, on or before January 1, 1998.
  Community colleges serve an instrumental role in both our educational 
and workforce systems, providing post-secondary education and job 
training, particularly to individuals and families hardest hit by 
difficult economic times. This includes workers eligible for training 
under the Trade Adjustment Assistance program for communities and for 
individuals who are, or may become eligible for unemployment 
compensation. To ensure that these institutions have access to the 
resources they need to develop and improve educational and career 
training programs designed to meet the needs of these communities, the 
legislation directs the Secretary of Labor to award Community College 
Career Training Grants especially to struggling 2-year public community 
colleges, (as defined in Section 101 of the Higher Education Act of 
1965). As the legislation ensures that all States benefit from these 
resources with the inclusion of a state minimum, I also encourage that 
the Secretary strive to ensure a diverse geographical representation of 
community colleges in both urban and rural areas.
  I'd like to thank Ruben Hinojosa, our higher education subcommittee 
chair, Tim Bishop, and all of our committee members for their tireless 
work on student loan reform.
  Along with all the members of our committee, I'd like to especially 
thank Rob Andrews, our health subcommittee chair, for his backbreaking 
work over the last year on health reform.
  And I would like to thank the many members of my staff for their long 
hours and tremendous work over the last year on these two pieces of 
reform: Mark Zuckerman, Danny Weiss, Alex Nock, Michele Varnhagen, Jody 
Calemine, Denise Forte, Ruth Friedman, Megan O'Reilly, Julie Radocchia, 
Jeff Appel, Ajita Talwalker, Celine McNicholas, Meredith Regine, 
Lillian Pace, Kara Marchione, Helen Pacjic, Rachel Racusen, Aaron 
Albright, Melissa Salmanowitz, Andra Belknap, Betsy Kittredge, Mike 
Kruger, Amy Peake and Courtney Rochelle.
  Their commitment and expertise has been invaluable.
  We almost didn't get here today. You know that.
  Opponents of health care reform have said anything and done 
everything to distort the

[[Page 4164]]

facts, delay the process, and try to put off what Americans have asked 
for and needed for generations. They have tried to sow fear into the 
American people.
  They cannot win on the merits. And they will continue to lie and 
distort the facts going forward. But we have made it to the final step 
in this process--despite all that noise.
  And now we face a simple choice.
  We can side with America's families and college students and make 
health insurance and college more affordable and accessible--while 
creating millions of jobs and reducing the deficit.
  Or, we can side with insurance companies and banks.
  That's it.
  That's the choice.
  I'm siding with the American people.
  I urge each of my colleagues to join me.
  The SPEAKER pro tempore. The gentleman from South Carolina (Mr. 
Spratt) is recognized for 15 minutes as a designee of the majority 
leader.
  Mr. SPRATT. I reserve the balance of my time.
  Mr. RYAN of Wisconsin. Mr. Speaker, I'd like to yield 2 minutes to 
the gentlewoman from Wyoming (Mrs. Lummis).
  Mrs. LUMMIS. The world is begging America to get its financial house 
in order. This Congress responds by doubling the debt in 5 years and 
tripling it in 10.
  Americans are begging for jobs, careers, and stability. This Congress 
responds by hiring 17,000 people at the IRS to enforce on Americans 
government-approved health insurance.
  Small business entrepreneurs beg Congress to empower them to create 
jobs. Congress responds with 20 new taxes in this health care bill, 
amounting to half a trillion dollars.
  Our military families beg us to leave TRICARE alone. This bill 
transfers TRICARE out of the Department of Defense.
  Americans are fed up with government takeovers of business, like the 
auto industry that closed dealerships and threw Americans out of work. 
This health care bill includes a government takeover of the student 
loan business, throwing 31,000 more Americans out of work.
  We Republicans implored the majority for a bipartisan health care 
reform bill. The majority party responded with special deals cut behind 
closed doors to garner votes from its most reluctant members.
  America deserves better than this. America is better than this. Let's 
listen to America. Kill this bill. Start over with health care we can 
afford. Create jobs and save our economy.
  Mr. RYAN of Wisconsin. Mr. Speaker, at this time I'd like to yield 
myself the remainder of our Budget Committee time.
  Mr. Speaker, there's a lot wrong with this bill. We know the problems 
with its costs. We know it doesn't really reduce the deficit. We know 
premiums are going to go up. The CBO has given us all this information 
and it's clear that we have a bill that is chock full of gimmicks and 
hidden mandates. I'm not going to get into all of that again, but what 
I want to ask is this: Why has this decision become so personal to our 
constituents? Why are so many people swarming the Capitol today? Why 
have we received a hundred thousand calls an hour from around the 
country? It's because health care affects every one of us. And yet, 
here we are, debating whether the government should have a bigger role 
in making those personal decisions.
  So make no mistake about it. We are not just here to pass a health 
care bill. We are being asked to make a choice about the future path of 
this country. The speakers to my left are correct: this is history. 
Today marks a major turning point in American history. This is really 
not a debate about prices, coverage, or choosing doctors. This is 
ultimately about what kind of country we are going to be in the 21st 
century.
  America is not just a nationality. It's not just a massive land from 
Hawaii to Maine, from Wisconsin to Florida. America is an idea. It's 
the most pro-human idea ever designed by mankind. Our Founders got it 
right when they wrote in the Declaration of Independence that our 
rights come from nature and nature's God--not from government.
  Should we now subscribe to an ideology where government creates 
rights, is solely responsible for delivering these artificial rights, 
and then systematically rations these rights?
  Do we believe that the goal of government is to promote equal 
opportunity for all Americans to make the most of their lives, or do we 
now believe the government's role is to equalize the results of 
people's lives?
  The philosophy advanced on this floor by this majority today is so 
paternalistic and so arrogant. It's condescending, and it tramples upon 
the principles that have made America so exceptional.
  My friends, we are fast approaching a tipping point where more 
Americans depend upon the Federal Government than upon themselves for 
their livelihoods, a point where we, the American people, trade in our 
commitment and our concern for individual liberties in exchange for 
government benefits and dependences.
  More to the point, Mr. Speaker, we have seen this movie before, and 
we know how it ends. The European-style social welfare state promoted 
by this legislation is not sustainable. This is not who we are and it 
is not who we should become.
  As we march toward this tipping point of dependency, we are also 
accelerating toward a debt crisis; a debt crisis that is the result of 
the politicians of the past making promises we simply cannot afford to 
keep. Deja vu all over again. It's unconscionable what we are leaving 
the next generation.
  This moment may mark a temporary conclusion of the health care 
debate, but its place in history has not yet been decided. If this 
passes, the request to reclaim the American idea is not over. The fight 
to reapply our founding principles is not finished. It is just a 
steeper hill to climb, and it is a climb that we will make.
  On this issue, more than any other issue we have ever seen here, the 
American people are engaged. From our town hall meetings to Scott 
Brown's victory in Massachusetts, you have made your voices heard and 
some of us are listening to you.
  My colleagues, let's bring down this bill and bring back the ideas 
that made this country great.
  Mr. SPRATT. Mr. Speaker, I first recognize the gentleman from 
California (Mr. Baca) for a unanimous consent request.

                              {time}  2115

  Mr. BACA. Mr. Speaker, I rise in strong support of this legislation.
  Mr. Speaker, I stand today in strong support of the health care 
reform the American people so desperately need.
  American families and small businesses--not insurance companies--
deserve control over their health care decisions.
  The bill we are debating today will:
  Lower insurance costs--and hold insurance companies accountable.
  End denial of coverage for pre-existing conditions.
  Provide coverage to 32 million uninsured Americans.
  Close the Medicare Doughnut Hole--so seniors will be able to afford 
the coverage they need.
  Eliminate waste in our current system--and lower the deficit by $138 
billion over 10 years; and $1.2 trillion over the next 20 years.
  And allow young adults to stay on their parents' insurance coverage 
until the age of 26.
  Health care reform is an issue that affects every single American--
but is especially important to our Hispanic American community.
  Forty-one percent of Hispanics over the age of 18 lack health 
coverage. We must do better--and with this bill--we will.
  Twenty-one percent of older Hispanics suffer from diabetes--compared 
to only 14 percent of non-Hispanic whites.
  The preventive care this bill provides will lower this disparity.
  This truly is a historic time.
  In 1935 we passed Social Security. In 1965, we passed Medicare.
  Today--we pass a health care reform that will save millions of 
lives--shrink our deficit, and put our nation on a path to prosperity.
  We must move past the hate, the fear, and the lies that have 
dominated this debate, and get the job done for the American people.
  I urge my colleagues to vote for this bill and pass health care 
reform that we need now and for generations to come.

[[Page 4165]]


  Mr. SPRATT. I yield to Mr. Israel of New York to make a unanimous 
consent statement.
  Mr. ISRAEL. Mr. Speaker, I rise in support of this bill.
  Mr. Speaker, I rise in support of this bill for one fundamental 
reason. It is simply the right thing to do. Not for my Party, not for 
the President, not for the Speaker, not for me. But for the people I 
represent. The middle class and working families; the backbones of our 
economy--small businesses--challenged by rising health costs.
  Few debates have been as long and as passionate as this one. Since 
last August I have heard the strong voices on both sides of this issue. 
I have listened to the angry chants of opponents of the bill at Town 
Hall meetings. I have read the mail from people who insist this is a 
march towards socialism, that it is a dangerous experiment, that it 
involves government death panels who will deny senior citizens the 
life-saving health care they need. I have watched protesters march 
outside my district office on Long Island. I have seen the repugnant 
signs here in Washington comparing health care to the Holocaust.
  I have seen and heard it all. But I have also heard others. They are 
the average Long Islanders--not rich, not poor, but usually somewhere 
in between--who live in quiet desperation and concern.
  The small business owner on Long Island who told me he just received 
a 22 percent increase in health insurance premiums and agonizes at the 
prospect of either scaling back the care he provides his workers or 
scaling back the workers he pays. Under this bill, his business will 
receive a tax credit to help him provide insurance to his workers. And 
he will be able to shop for competitive rates and services in a new 
market-driven ``Health Insurance Exchange.''
  The woman who thought health care worked pretty well for her, until 
her daughter was diagnosed with breast cancer. She's been forced to 
deal with high medical costs to care for her daughter. But, under this 
bill, she will not have to worry about an insurance company that 
refuses to pay for her chemotherapy.
  The middle class family with two kids just out of college who are 
having trouble finding a job that provides health insurance. Under this 
bill, those young adults can get coverage on their parents' plans until 
they turn 26.
  The retired plumber on the block where I live. One day he came to my 
house. I thought he wanted to debate this bill with me. Instead, he 
said: ``I wish you would pass this now. Don't these people know that if 
they lose their jobs they lose their health care?''
  And just yesterday, Mr. Speaker, a small business owner called me 
with concerns and plentiful questions about the legislation we will 
vote on today. After I explained it, he said: ``There's been too much 
confusion about this bill. I wish it had been explained.''
  He is right. This bill has changed in over a year of debate. 
Sometimes in an effort to accept bipartisan recommendations. Sometimes 
to reduce its cost. While one side has had the responsibility to 
improve the bill, the other side has taken the opportunity to brand it 
with mischaracterizations. But now the ink is dry, Mr. Speaker. And the 
dry ink of this bill represents the best hope to protect the middle 
class and working families I represent. The small business owner in 
East Northport who now has a level playing field when shopping for 
insurance. The family in Sayville who can now keep a child insured 
until the age of twenty-six. The senior in Deer Park whose drug costs 
will be covered. The accountant in Huntington who lost his job but will 
be able to shop for affordable health care.
  This bill will improve coverage for 485,000 of my constituents with 
coverage through their employer, give tax credits to as many as 81,000 
families and 21,000 small businesses to make health care affordable in 
my district, and extend coverage to 29,000 uninsured residents of the 
towns I represent.
  This bill will reduce our debt. Yesterday, the Congressional Budget 
Office certified that the bill is fully funded and will actually reduce 
federal deficits by $143 billion in the first 10 years and over a 
trillion dollars in the next 10.
  This bill is an urgent reversal from 8 years of ignoring the crisis. 
Between 2000 and 2008, health insurance premiums doubled, insurance 
company profits quadrupled, and an additional 6 million Americans 
became uninsured. As a result, the leading cause of personal bankruptcy 
today is unpaid medical bills. Without action, these trends will grow 
worse.
  These are the middle class families and businesses that have always 
expanded our economy. But rising health costs and insecurity have 
undermined the middle class. This bill will provide them with the basic 
security they need to do what they've always done: build our economy.
  This vote is no different than the 1965 vote for Medicare. Back then, 
when one quarter of American seniors were living in poverty and wracked 
with unpayable medical bills, there were loud voices that said, ``do 
nothing'' and ``start over'' and ``vote no.'' Public opinion was 
skeptical then. Had I been in Congress in 1965, and the choice was 
voting for Medicare and risking my seat, or voting against Medicare and 
saving my seat, I would have voted for Medicare. It became the backbone 
of economic security for our senior citizens and helped build a middle 
class with economic security. This is no different. No less necessary. 
No less historic.
  Mr. SPRATT. Mr. Speaker, I yield to the gentlewoman from Ohio for a 
unanimous consent request.
  Ms. SUTTON. I rise in support of this historic legislation.
  Mr. Speaker, every year 45,000 people in this country die because 
they do not have insurance coverage, and in this great nation it should 
not be that way. And, on this day, in this moment, we have been called 
to stand up and vote to put an end to that sad reality.
  This is the moment when we will finally take the long-overdue step of 
ending the unconscionable practices of the insurance companies, who 
through their greed and disregard have enjoyed record profits even as 
American families have suffered, sometimes fatally because of their 
actions.
  I support this legislation because it will put a stop to the 
discriminatory practices by insurance companies that deny care based on 
pre-existing conditions and impose outrageous premium increases on 
American families.
  I support this legislation because it will cap out-of-pocket expenses 
that insurance companies impose on our constituents forcing many into 
bankruptcy when they or their children are stricken by illness or 
injury.
  I support this legislation because it is a vote to stop insurance 
companies from inflicting lifetime caps on people who have paid for 
insurance, only to find that it was not there for them when they needed 
it most.
  I support this legislation, because it will strengthen the solvency 
of Medicare, lower drug costs and close the donut hole for our seniors, 
and has the support of the AARP.
  This legislation will make health insurance more affordable and 
accessible for small businesses and individuals.
  This legislation will finally curb the perpetual, skyrocketing costs 
of health care that have been drowning far too many American families 
for far too long.
  This measure will reduce our deficit by more than $1.3 trillion in 
the next two decades.
  I support this legislation because within the 13th District of Ohio, 
which I am so honored to serve, it will improve coverage for 420,000 of 
my constituents with health insurance.
  It will give tax credits and other assistance to up to 154,000 
families and 13,200 small businesses to help them afford coverage.
  It will improve Medicare for 107,000 beneficiaries, including closing 
the donut hole. ``It will extend coverage to 33,500 uninsured residents 
of the 13th District.
  It will guarantee that 9,000 residents with pre-existing conditions 
can obtain coverage.
  It will protect 1,700 families from bankruptcy due to unaffordable 
health care costs. ``It will allow 45,000 young adults to obtain 
coverage on their parents'' insurance plans.
  It will help support 3 community health centers in the 13th District 
and reduce the cost of uncompensated care for hospitals and other 
health care providers by $34 million annually.
  For all of these reasons, this is the day, this is the moment, and I 
am honored to support this health care measure.
  Mr. SPRATT. Mr. Speaker, I yield myself 2 minutes.
  Congress cleared the way for health care reform in the budget 
resolution. And when we did, we stipulated that reform had to be 
deficit-neutral. We can now say that the House, Senate and President 
have all abided by this principle. The bill put before us has been 
scored by the Congressional Budget Office. In this case, CBO found that 
the 10-year cost of all the covered changes in the bill put before us 
amount to $788 billion. But the bill before us also includes 
reductions, savings, and new revenues which total $931 billion.
  When the $931 billion is netted against the $788 billion, the result 
is a net savings, which reduced on-budget deficits over the next 10 
years by $143 billion. That's CBO's estimate of the first 10 years 
under these reforms, a reduction in the deficit of $143 billion. What 
about the next 10 years? CBO estimates that these two bills together 
will save around .5 percent of GDP over the second 10 years. Now that 
may

[[Page 4166]]

sound minimal, but during that period of time, GDP cumulatively is $272 
trillion, so .5 percent of that easily equals more than $1.2 trillion.
  You will hear numbers of all sorts in this debate, but remember these 
because they come from a disinterested source with a well-proven 
record. This is what CBO estimates as the effects of these bills on the 
deficit: a reduction of $143 billion over the next 10 years and a 
reduction of $1.2 trillion over the following years. We have kept the 
promise we made at the outset by keeping health care reform deficit-
neutral, and that's one more reason to vote for this bill.
  I reserve the balance of my time.
  The SPEAKER pro tempore. The gentleman from Michigan (Mr. Camp) is 
recognized for 20 minutes as a designee of the minority leader.
  Mr. CAMP. Mr. Speaker, at this time I yield 3\1/2\ minutes to the 
distinguished gentleman from Indiana (Mr. Pence), our conference 
chairman.
  Mr. PENCE. This is truly a remarkable moment in the life of this 
Nation. Some say we're making history. I say we're breaking history. 
We're breaking with our finest traditions--limited government, personal 
responsibility and the consent of the governed. The first principle of 
public service in a free society is humility. The arrogance we've 
witnessed in this institution is breathtaking. Only in Washington, 
D.C., could you say you're going to spend $1 trillion and save the 
taxpayers money. Only in Washington, D.C., could you exchange the pro-
life protections enshrined in the law for 30 years for a piece of 
paper, signed by the most pro-abortion President in American history.
  Despite overwhelming public opposition today, this administration and 
this Congress is poised to ignore the majority of the American people. 
Let me say, Mr. Speaker, this is not the President's House. This is not 
the Democrats' House. This is the people's House, and the American 
people don't want a government takeover of health care. Now I know they 
don't like us to call it that. But when you mandate every American to 
have government-approved insurance, whether they want it or need it or 
not, when you create a government-run plan, paid for with job-killing 
tax increases, and you provide public funding for abortion, that's a 
government takeover of health care, and the American people know it.
  The American people want to face our challenges in health care with 
more freedom, not more government. And this really is about freedom. 
The more I think about this debate, the more I think about what Ronald 
Reagan said in 1964. He said then and now, It's about whether we 
abandon the American Revolution and confess that a little intellectual 
elite in a far distant capital can plan our lives better than we can 
plan them ourselves.
  You know, today we gathered in the old House Chamber for a time of 
worship and prayer. Members of Congress have been doing that for about 
200 years. It's a Chamber filled with statues of great Americans: Sam 
Houston, Lew Wallace, Robert Fulton, William Jennings Bryan, soldiers, 
heroes and heroines of freedoms past. As I sat there, I thought of that 
Bible verse that said, ``We are surrounded by such a great cloud of 
witnesses.'' Standing here tonight, I believe we are as well. And I 
mean, not just those that are looking in tonight from here and around 
the country, but those who have gone before. Men and women who did 
freedom's work in their time who persevered, who made this the greatest 
Nation on Earth possible.
  Now it's our turn. We can reform health care without putting our 
country on a pathway towards socialized medicine. We can reform health 
care by giving the American people more choices, not more government. 
So I say to my Democratic colleagues, stand with those who have gone 
before and made the hard choices to defend freedom in their time. Stand 
with us. Stand for freedom, and the American people will stand with 
you.
  Mr. SPRATT. Mr. Speaker, I yield for a unanimous consent request to 
Ms. Fudge of Ohio.
  Ms. FUDGE. Mr. Speaker, I rise in support of this health care 
legislation.
  Mr. Speaker, I rise today to vote for my constituents. Ohioans want 
health care reform and they want it now. They told me: `` Now is the 
time to stand for change. Now is the moment to fight for quality 
care.''
  I'm voting for Vera--a former nurse who lost her insurance after a 
divorce, despite a lifetime of caring for others. She has over ninety 
thousand dollars in medical debt, as a result of her 3 strokes.
  I'm voting for ``Mary's'' mom, who faced cancer without health 
coverage. ``Mary's'' mom died in her daughter's arms in pain and 
without medication because she had no insurance.
  I'm voting for the father in my District, who is forced to choose 
between maintaining his child's health insurance or meeting his monthly 
bills. He shouldn't have to choose between treating his son's sickle 
cell disease and putting food on the table.
  As a pastor said this morning:
  I'm voting like unborn children depend on me.
  I'm voting like a single mom in East Cleveland depends on me.
  I'm voting like seniors in Warrensville Heights depend on me.
  I'm voting like foster youth are waiting on me.
  I'm voting for the person in Euclid who died too soon.
  I'm voting like I don't have health care insurance myself.
  I'm voting for justice and equality.
  I'm voting for health care reform, so that I can hold my head high, 
look my neighbors in the eye and tell them: ``I voted for you, and you, 
and you.''
  Mr. SPRATT. Mr. Speaker, could I inquire as to the remaining time?
  The SPEAKER pro tempore. The gentleman from South Carolina has 13\1/
2\ minutes, and the gentleman from Michigan has 16\1/2\ minutes.
  Mr. CAMP. Mr. Speaker, at this time I yield 2 minutes to the 
distinguished gentleman from California (Mr. McCarthy).
  Mr. McCARTHY of California. Mr. Speaker, this is the people's House, 
and we were sent here to represent people throughout America. Some are 
actually in the gallery, some have been marching around this building, 
some are sitting at home watching on TV. Or they're in their car 
driving back from church, and many of them have been calling this 
Congress. And they've been asking one thing, Why does Washington refuse 
to listen? They see what many on this side of the aisle see, the 
arrogance of Washington. We are here to represent our constituents, 
which is why we are asking, Why are we voting on a health care bill 
today that empowers government instead of the people?
  Survey after survey demonstrates the great unpopularity of today's 
bill. Not only the substance of it, but the trickery, the deals and the 
shortcuts that led us to where we are today. But this bill is being 
pushed through because the majority in this Congress refused to listen 
to the people. The Speaker has even said that she believes that we have 
to pass this bill so people can find out what's in it. The logic here 
is, Washington knows better than the people.
  All this at a time when Washington is borrowing 43 cents out of every 
dollar it spends, adding to our national debt, mortgaging our 
children's future. And this $2.4 trillion bill will steal even more 
money from our children's futures at a time when this administration 
and Congress are poised to run up the debt more than any other 
administrations combined. It doesn't have to be this way. We could have 
easily found a positive bipartisan agreement on commonsense health care 
reforms that reduce the costs, increase competition and increase 
access, all without raising the debt. Today is a legacy vote for 
Members of this people's House, and I urge my colleagues to start over 
and craft the bill to solve the problem.
  Mr. SPRATT. Mr. Speaker, I yield to the gentleman from North Carolina 
(Mr. Watt) for a unanimous consent request.
  Mr. WATT. Mr. Speaker, I rise in support of the 32 millions Americans 
who will get insurance under this bill.


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. Under clause 7 of rule XVII, Members may not 
refer to the occupants of the gallery.
  Mr. SPRATT. I now take pleasure in yielding 3 minutes to my colleague 
from South Carolina (Mr. Clyburn), the majority whip.

[[Page 4167]]


  Mr. CLYBURN. I thank the gentleman for yielding me the time. Mr. 
Speaker, we have come to a defining moment in our Nation's history. 
Tonight I am thinking about the woman who called in to a talk radio 
program that I appeared on last August. She called in to take issue 
with the gentleman who had just called in earlier to say that he did 
not support our efforts to reform the health care system because he 
liked the insurance he had. The caller shared her experiences of having 
been dropped from coverage by an insurance company she thought she 
liked just as she started her second treatment for breast cancer. She 
said to the gentleman that maybe he liked the insurance he had because 
he had never tried to use it.
  With these reforms, dropping people from coverage when they are 
diagnosed with catastrophic illnesses will no longer be allowed, and 
denying insurance to children with diabetes and other preexisting 
conditions will end immediately. These reforms will allow children to 
remain on their parents' insurance policies until their 26th birthday. 
This bill will immediately begin closing the doughnut hole for 
prescription medications for seniors and eliminating burdensome copays 
or deductibles for their preventive care.
  Despite deafening protests from the other side, the nonpartisan 
Congressional Budget Office says that the reforms included in this bill 
will reduce our deficit by $143 billion in the first 10 years and $1.2 
trillion in the second 10 years. This bill will also create jobs, 
400,000 good-paying jobs, reliable jobs for every year and for small 
businesses. Small businesses will get a tax break on their health care 
premiums that will free up money for them to hire 80,000 more 
employees.
  Mr. Speaker, we have debated this issue for several generations. The 
time has come to act. This is the Civil Rights Act of the 21st century, 
and tonight we will take a significant step to move our country 
forward.
  Mr. CAMP. Mr. Speaker, at this time just for the purpose of a 
unanimous consent request, I yield to the gentleman from Pennsylvania.
  Mr. DENT. Mr. Speaker, I rise in opposition to this flawed health 
care bill.
  Undeniably, health care reform is needed. Families and businesses are 
struggling to keep up with rising insurance premiums. Thousands of 
constituents in my district do not have access to affordable insurance 
because of skyrocketing costs. An increasing number of Americans are 
impacted by policies that preclude individuals with pre-existing 
conditions from securing insurance. Patients are frustrated with the 
difficulty of navigating the health care system and insurance 
bureaucracy. We have all experienced our doctors practicing defensive 
medicine--ordering unnecessary tests and procedures in an effort to 
ward off frivolous lawsuits. Poor reimbursement rates mean that doctors 
cannot afford to place an emphasis on prevention and wellness.
  The consequences of reform are profound for families, our economy and 
the future of our country. Reform policies will have a direct impact on 
the lives of all Americans and the budgets of every household. These 
changes will affect one-sixth of our economy. Done right, we will lift 
burdens that are holding employers back from growing and revitalizing 
our economy. Done wrong, jobs will be lost and 10 percent unemployment 
will become the norm rather than the exception. Health care 
expenditures make up an increasing percentage of state and federal 
spending. Addressing health care costs is vital to the long-term 
economic health of the United States.
  I support reform. I have advocated for deliberate policies that will 
reduce the cost and increase the quality of health care, provide all 
Americans with the opportunity to obtain affordable health insurance, 
give patients more control over their health care decisions, and 
promote innovations and wellness initiatives that lead to cures.
  I oppose the bill before us today because it will increase health 
care costs for Americans and bend the curve of health care spending in 
the wrong direction; it will create a new trillion dollar entitlement 
program that the bill does not realistically address how we will 
afford; and it will impede economic growth, particularly in our 
district.
  Above all else, health care reform must address the escalating health 
care costs that are crippling American families and overall, slow our 
nation's healthcare spending. This bill does not accomplish those 
critical objectives. According to an analysis by the Congressional 
Budget Office (CBO), premiums will increase by 10 to 13 percent for 
families who are purchasing health insurance in the individual market. 
This amounts to more than $2,000 a year for a family. In addition, the 
CBO indicates that H.R. 3590, which will be the law of the land if we 
pass it today, will increase the federal budgetary commitment to health 
care by more than $200 billion over the next decade. If the 
reconciliation package (H.R. 4872) is also signed into law, the 
combined budgetary impact on health care spending will be $390 billion. 
American families can't afford that increase and neither can our 
country.
  Moreover, this bill creates an unsustainable new entitlement program 
at the expense of seniors who will be impacted by more than half a 
trillion dollars in Medicare cuts and all Americans who will pay higher 
health care costs and more than half a trillion dollars in increased 
taxes, fees and penalties. The bill uses ten years of taxes and 
Medicare cuts in order to pay for six years of programs. Overall, in 
the first 10 years of full implementation (2014 to 2023), the health 
care package will result in more than $2.6 trillion in spending. 
Although the CBO estimated the overall deficit reduction will be $124 
billion over 10 years, in its analysis the CBO cautioned that its long-
term deficit projections ``reflect an assumption that the key 
provisions of the reconciliation proposal and H.R. 3590 are enacted and 
remain unchanged throughout the next two decades, which is often not 
the case for major legislation. For example, the sustainable growth 
rate mechanism governing Medicare's payments to physicians has 
frequently been modified to avoid reductions in those payments, and 
legislation to do so again is currently under consideration by the 
Congress.''
  House Leadership has already said it will consider a bill to address 
the physician payment issue. Just that policy alone will cost $200 
billion, which is not reflected in the CBO score.
  Finally, this bill will have an immediate impact on economic growth. 
New taxes and regulations will lead to lower wages, lost jobs and 
decreased investment. Employers with more than 50 employees who do not 
provide health insurance coverage that is deemed ``acceptable'' by 
federal standards will be saddled with a tax of up to $2,000 per 
employee. The bill will levy a tax of as much as 2.5 percent of 
household income on Americans who do not comply with the individual 
mandate, which requires all Americans to maintain acceptable coverage. 
Many investors will face a new tax of 3.8 percent on capital gains, 
dividends, interest, rents, royalties and other investment income. This 
tax coupled with scheduled rate increases will lead to a top rate of 
23.8 percent for capital gains and 43.4 percent for dividends.
  We will feel the impact close to home. A 2.3 percent medical device 
tax will increase the cost of medical devices--everything from tongue 
depressors to wheelchairs--and discourage the development of critical 
new medical innovations. Specifically, this tax will impact businesses 
in our district imperiling jobs; curtailing advanced research and 
innovation; reducing purchasing from Pennsylvania vendors; and 
hampering investment in capital equipment. The ripple effect on our 
economy and on working families will be far greater than the sum of the 
tax. And ultimately, patients will see increased costs as a result.
  Just yesterday, I offered two amendments to the Rules Committee that 
would have reduced the negative impacts of H.R. 3590. The first 
amendment would have inserted common-sense medical liability reforms. 
Specifically, the amendment would enact nationwide reforms aimed at 
ending the costly practice of defensive medicine and encourage states 
to adopt effective alternative medical liability laws that will reduce 
the number of health care lawsuits that are litigated and the average 
amount of time taken to resolve lawsuits, and reduce the cost of 
malpractice insurance. The provisions would save our country billions 
of dollars and reduce national health care spending. The second 
amendment would have struck the ill-advised medical device tax that a 
company in my district has dubbed the ``death tax'' because it will 
increase their tax burden by 77 percent, raising their effective tax 
rate to over 73 percent. This is an innovation tax that will mean less 
investment in research and development that leads to medical 
innovations. Unfortunately the leadership of the House would not allow 
these important amendments to be debated on the House floor today.
  I regret very much where we are today and wish that bipartisan 
efforts to address the shortcomings of our system--access and 
affordability--while building on our strengths--choice, quality and 
innovation had prevailed.

[[Page 4168]]


  Mr. CAMP. At this time, Mr. Speaker, I yield 2 minutes to the 
distinguished gentlewoman from Washington (Mrs. McMorris Rodgers).
  Mrs. McMORRIS RODGERS. Mr. Speaker, I know that some of my colleagues 
on the other side of the aisle are still undecided, and I sincerely 
urge you to vote ``no.'' This is the wrong bill at the wrong time. At a 
time when 15 million Americans are out of work, this is the wrong time 
to hit small businesses with more taxes and more requirements. At a 
time when premiums are surging for working families is the wrong time 
to pass a bill that everyone acknowledges is actually going to increase 
premiums.
  At a time that we have a $3.8 trillion budget, 40 percent of which is 
deficit spending and is being put on the credit card, this is the wrong 
time to pass a new massive government spending program. And at a time 
when Americans are losing trust in Congress, it is the wrong time to 
strike backroom deals and pass a bill over the will of the people.
  Everybody in this body acknowledges the need for real health care 
reform. But this health care reform will make things worse, not better, 
for the people we serve. We should not let the hunger to do something--
anything--trick us into passing a bill that will cripple free 
enterprise and permanently diminish the freedom of the American 
individual.
  Today I'm reminded of a quote by President Ford: ``A government that 
is big enough to give you everything you want is a government big 
enough to take it all away.'' This is a time for courage and clear 
thinking. I urge my friends on the other side of the aisle to join in 
standing with the American people and vote against this bill.

                              {time}  2130

  Mr. SPRATT. Mr. Speaker, I yield 2 minutes to the gentlewoman from 
Pennsylvania (Ms. Schwartz).
  Ms. SCHWARTZ. Mr. Speaker, health care reform represents the largest 
deficit-reduction measure in nearly a generation while controlling the 
rising cost of health care for families and businesses, and improving 
access to and quality of coverage for 95 percent of Americans.
  This plan strengthens coverage and health care for all Americans, 
including provisions that I have fought hard for: prohibiting insurance 
companies from excluding coverage for preexisting conditions for 
children and adults; prohibiting insurers from dropping coverage when 
you get sick, or placing annual or lifetime limits on benefits; 
insuring that all insurance policies use plain, easy-to-understand 
language so that consumers know what they are buying and can honestly 
compare their choices; allowing young adults up to the age of 26 to 
stay on their parents' policies; offering tax credits to small 
businesses so they can afford to provide insurance coverage for their 
employees; eliminating copayments for preventive care for seniors; 
closing the Medicare prescription drug coverage known as the doughnut 
hole, making sure that we close that doughnut hole; promoting the 
important education and research missions of our Nation's teaching 
hospitals and academic medical centers which train the next generation 
of doctors and nurses; focusing on primary care by better ensuring 
Americans, particularly those with chronic diseases, have access to 
ongoing primary care; investing in American innovation and technologies 
by creating new incentives for the development of new cures and 
treatments; and incentivizing collaboration among health providers 
through new payment reforms that promote high quality, efficient 
delivery of care.
  These provisions, and others, in health reform ensure new consumer 
rights and protections for those with insurance. It contains costs for 
families, businesses and for our Nation. And it extends affordable, 
meaningful coverage to 32 million Americans. Health care reform is 
vital to the health of Americans and the health of our economy. The 
status quo is unacceptable and unsustainable. I urge a ``yes'' vote.
  Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentleman from California (Mr. McKeon).
  Mr. McKEON. Mr. Speaker, I rise in opposition to this flawed health 
bill.
  Mr. CAMP. Mr. Speaker, I yield 3 minutes to the distinguished 
gentlewoman from West Virginia (Mrs. Capito).
  Mrs. CAPITO. Mr. Speaker, for a moment let's think of this bill as a 
blanket, a blanket of health care legislation that may be draped across 
America and its population in the coming years. Unfortunately, this 
blanket is woven not from all hands working together, but is the 
handiwork of strong-arm, political deal-making, and, perhaps most 
disheartening, a resistance to listen to the American people.
  Its cloth has been cut behind closed door, and its color is tinged by 
partisan hands. It is too short in some areas, and too long in others, 
woven to cover the winners and to leave out the losers. Once this 
blanket of legislation is laid out, those that huddle beneath it will 
find that it does not provide the real health care reform they need for 
their families. In fact, it will become a wall of government between 
them and their doctor.
  Its huge holes will not protect the cold wind of job loss, new taxes, 
government bureaucracy, and increased health care costs. And though we 
hear of coming patches in the future, in all likelihood they will be 
made of the same flimsy fabric of broken promises.
  All of America will feel the weight of this uncomfortable burden. The 
real cost of the $2.6 trillion bill will only increase in the future. 
States like mine, West Virginia, will feel the weight in huge budget 
shortfalls caused by millions of dollars in unfunded mandates. States 
must balance their budgets and will be forced to absorb the massive 
increase in Medicaid spending demanded by this bill.
  But, the full burden will be paid by those who enjoyed this beautiful 
spring day, playing outside in backyards across America. Little do they 
know as they play that we are on the cusp of burdening them with 
generational debt. The Speaker and her team will drape this legislation 
across citizens, ignoring their pleas against it. And America will 
again shake its head in disbelief and ask how Washington can turn a 
deaf ear and be so disconnected from the American people.
  If we stand here in obedience to our purpose, the Congress will be an 
effective representation of the people of the United States. We should 
stop this unfortunate endeavor, take a step back and listen, listen to 
the heartbeat of America, the beat that yearns for true health care 
reform, the beat that asks for bipartisan government committed to 
solving America's problems, the beat that asks that we put America's 
families first. America deserves this. America deserves to be heard.
  Mr. SPRATT. Mr. Speaker, I yield 2 minutes to the gentleman from 
Florida (Mr. Boyd).
  Mr. BOYD. Mr. Speaker, I thank my friend, Mr. Spratt from South 
Carolina.
  Mr. Speaker, ladies and gentlemen, I heard a wise man once say that 
you never saw a great country with an uneducated and unhealthy 
population. We are headed there. Sixty-seven thousand uninsured in the 
congressional district that I represent will be helped by this bill. We 
all know the statistics about the spiraling cost of insurance and the 
ever-increasing percentage of uninsureds within our own districts and 
across this Nation. We all agree this is an unsustainable path. I have 
heard you say it many times. So I ask you, How high do these numbers 
have to go before we act?
  Earlier I heard the gentlelady from Washington State say it is the 
wrong time. For 22 years in my legislative service, as I have been 
trying to find solutions, I have heard it is the wrong time. I know 
many of you have been trying to find those solutions, too, from time to 
time; solutions for those high costs, the spiraling high costs, the 
ever-increasing number of uninsureds on an annual basis, solutions that 
would do it in a fiscally responsible way and use the good parts of our 
private-sector delivery system. Ladies and gentlemen, this bill does 
all four of those things.

[[Page 4169]]

  Mr. Speaker, if we fail to act now, the path we are on will create a 
society of haves and have-nots based solely on one's ability to 
purchase health insurance.
  I know this bill isn't perfect. There are some things in it that I 
don't like; but seldom are bills perfect the first time around. The 
other side has brought us no viable alternatives. So then I ask you, 
ladies and gentlemen, if not this, then what? If not now, then when?
  Mr. Speaker, I urge my colleagues to vote ``yes'' for the health of 
our people and the strength of our economy.
  Mr. CAMP. For the purposes of a unanimous consent request, Mr. 
Speaker, I yield to the gentleman from Nebraska (Mr. Smith).
  Mr. SMITH of Nebraska. Mr. Speaker, I rise in opposition to this 
flawed health care bill.
  Mr. CAMP. Mr. Speaker, at this time I yield 3 minutes to the 
distinguished gentleman from Tennessee, Dr. Roe.
  Mr. ROE of Tennessee. Mr. Speaker, today we debate and vote on the 
most important piece of social legislation in decades, a massive 
expansion of government unparalleled in our Nation's history, with the 
potential to bankrupt future generations by lowering the standard of 
living for our children and grandchildren.
  For the past 30 years, I haven't been a politician, but a physician, 
treating patients and delivering babies in rural east Tennessee. And I 
can say without hesitation that we have in this country the highest 
quality of health care in the world. But I will also say that this care 
is too expensive for an increasing number of people.
  Health care should not be a partisan issue. I have never operated on 
a Republican or a Democrat cancer in my life. We have heard about how 
this is going to save money and reduce the budget deficit. Seventeen 
years ago in Tennessee we tried a plan called TennCare. It was an idea 
where different companies were going to compete and we were going to 
cut costs. What happened in that? Just 10 budget years later, our costs 
had tripled and we had to cut the rolls in Tennessee because the State 
was literally going bankrupt. And this year for the first time, we have 
had to limit patients' visits to 8 doctor visits per year, and this 
plan will only pay $10,000, I don't care what the cost of the care is, 
and those costs are shifted to private insurers. Also the physicians 
are not taking TennCare because it pays them less than 60 percent of 
their costs of actually providing the care. That approach, which is 
pretty much the same approach we are voting on here today, failed, and 
I know because I am a physician who worked in that system.
  Mr. Speaker, I have one question for every Member of this body: If we 
have seen how this Big Government scheme doesn't work, why would you 
vote for it again? Well, the States know. They are already well ahead 
of the Federal Government. Thirty-seven States, including Tennessee, 
are now proposing legislation to opt out if the ObamaCare plan should 
pass.
  So the States get it because they can't afford it. The seniors get it 
because they understand $500 billion will be cut from this program. And 
let me tell you, in the next 10 years we are going to add 35 million 
people to the Medicare rolls in this country when the baby boomers hit. 
Three things will happen when that occurs: you will decrease access; 
you will decrease quality because you can't see your doctor; and costs 
will go up. So seniors get it.
  The doctors get it. They are going to work harder and get paid less. 
Also, there is no meaningful tort reform, and without that, you cannot 
reduce the cost of care. The American people get this. The people of 
Tennessee don't want this plan. The people of the United States don't 
want this plan; but the politicians who vote for it are not listening.
  I choose to listen to the American people and vote ``no,'' and urge 
my colleagues to do the same.
  Mr. SPRATT. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentleman from New York (Mr. Meeks).
  Mr. MEEKS of New York. Mr. Speaker, I rise in support of this 
historic legislation.
  Mr. Speaker, I rise in support of Affordable Care for America.
  I am proud to stand with my colleagues in the U.S. House of 
Representatives in support of this critical legislation to ensure that 
each and every American has access to affordable, quality healthcare. 
This bill will put Americans and small businesses back in charge of 
their health care choices and make coverage affordable for everyone. 
Premium tax credits and cost-sharing assistance will be offered to low- 
and middle-income Americans, which will be the largest tax cut for 
health care in the history of this nation.
  My constituents in the Sixth Congressional District and across the 
country will be provided the opportunity to make informed decisions 
about their health insurance and purchase the plan of their choice.
  It is extremely important that every hard working American receives 
affordable high quality healthcare. This critical legislation will 
extend coverage to 95 percent of all Americans when passed. For the 
Sixth Congressional District this means that 54,000 residents who 
currently do not have health insurance will receive coverage.
  By passing this historical legislation we will be able to provide the 
people of the United States the proper healthcare they deserve. No 
American should be denied the right to better and affordable health 
care coverage. No American should be discriminated against by insurance 
companies based on pre-existing conditions, health status and gender. 
No American should be forced into medical bankruptcy because their 
Medicare access was terminated. I urge my colleagues in the House of 
Representatives to vote ``yes'' so no American is told ``no'' again.
  Mr. SPRATT. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentlewoman from California (Ms. Roybal-
Allard).
  Ms. ROYBAL-ALLARD. I rise in strong support of this bill.
  Mr. Speaker, I rise in support of the Senate Amendments to H.R. 
3590--the Patient Protection and Affordable Care Act. This legislation 
represents a milestone in our Nation's history. Building on the promise 
that was begun with the passage of Medicare in 1965, we take an 
historic step today toward acknowledging health care as a universal 
right for everyone.
  The people of America have suffered far too long from a health care 
system that is unaffordable, discriminates on the basis of gender, 
disability, and pre-existing conditions, and frequently denies coverage 
for lifesaving services and treatments. While we pay more than any 
other country in the world for health care, we die younger with the 
highest rate of preventable deaths among 19 industrialized nations. 
Obviously this status quo is unsustainable and the time for change is 
now.
  The bill we are voting on today reflects many long months of 
discussion and compromise. Clearly it is not perfect, and many of us 
would have preferred to see the bill go much further towards granting 
universal access to health care for every man, woman and child in this 
country. But with an issue that impacts so many stakeholders, and 
involves so many competing interests, it is doubtful that any single 
legislative effort could ever satisfy everyone and address all the 
problems we face in our current system.
  So while this bill falls short of what many of us had hoped would be 
included in a final bill, I believe it is critical that we move forward 
today in response to a crippled health care system that has been 
failing our country. With the passage of this bill we will improve the 
quality and affordability of health services, prioritize prevention and 
the reduction of health disparities, and take the necessary albeit 
difficult steps to rein in the escalating costs of health care in this 
country.
  I will be voting for this bill today for the people in my 34th 
Congressional District of California. Over 23 percent of my 
constituents live below the federal poverty level, and 40 percent of 
them are uninsured. In 2008, over 1100 of my constituents faced health 
care-related bankruptcies caused primarily by health care costs that 
were not covered by their insurance. This bill will extend coverage to 
185,000 of my constituents, and will guarantee that 28,500 residents 
with pre-existing conditions can obtain coverage while protecting those 
who do have insurance from bankruptcy due to unaffordable health care 
costs.
  I will be voting for this bill today for the small businesses in my 
District. With its passage, over 16,000 small businesses in my district 
that have 100 employees or less will be able to join the health 
insurance exchange, benefiting from group rates and a greater choice of 
insurers. H.R. 3590 will also help make small businesses more 
competitive by providing tax credits that will make it more affordable 
for them to offer health insurance to

[[Page 4170]]

their employees. In my district approximately 15,000 small businesses 
would qualify for these credits.
  As chair of the Congressional Hispanic Caucus Health Task Force, I 
will be voting for this bill today for Hispanic communities all across 
the country. It is of great concern to me that this segment of the 
population continues to face the highest uninsured rate of any racial 
or ethnic group within the United States. In fact, a recent report 
found that 42 percent of Hispanic adults lacked health insurance 
compared to the national average of 16 percent.
  This legislation will provide access to affordable health care to the 
millions of uninsured Latinos in this country through Medicaid 
expansion. The legislation will also provide access to health insurance 
exchanges and subsidies to help low- and moderate-income families. 
Additionally, the bill expands Community Health Centers which have been 
a cornerstone of primary care services in communities of color, and 
expands coverage for preventive care which has been disproportionately 
inaccessible to minorities.
  Finally, I will be voting for this bill today for the women and 
mothers in this country who have long managed the health care of their 
children, their spouses, and the elderly in their families. This 
legislation will mandate coverage for maternity care, so all women will 
be able to give their babies the healthiest start in life.
  By preventing insurance companies from dropping coverage for extended 
illness or denying coverage for pre-existing conditions, it will give 
moms the peace of mind knowing that their children and spouses will 
have the health coverage they need if they become ill or suffer from a 
genetic condition or disability. As their young adult children start 
out in life they can protect them by keeping them on their family 
insurance policy until their 26th birthday
  And who among us will not be more secure knowing that our parents 
will be protected from the Medicare Part D donut hole which has made 
life saving medications so unaffordable for those that need them most?
  Mr. Speaker, I thank you for your courage, tenacity and leadership 
throughout this year of deliberation on Health Care Reform. We owe you, 
the Majority Leader, and the Leadership team of this House a debt of 
gratitude for bringing this House to this historic day. I am proud to 
cast my vote for the passage of the Senate Amendments to H.R. 3590--the 
Patient Protection and Affordable Care Act.
  Mr. SPRATT. Mr. Speaker, I yield 2 minutes to the gentleman from 
Virginia (Mr. Scott).
  Mr. SCOTT of Virginia. Mr. Speaker, America has been debating health 
care for over 100 years, and during this debate we have heard 
complaints and blame and misrepresentations, slogans, even name-
calling. But today, we finally get to discuss the bills.
  The bills will provide affordable health care insurance to over 30 
million Americans who are uninsured today, including those with 
preexisting conditions. These bills will provide security for those who 
have insurance because 14,000 Americans will no longer lose their 
insurance every day, and others will no longer have to watch the cost 
of their insurance skyrocket every year.
  Insurance companies will no longer be able to cancel policies or stop 
making payments in the middle of an illness. No longer will those with 
health care have to make copayments for preventive services, or go 
bankrupt, because the bills provide affordable limits on copays and 
deductibles.
  And because the legislation will provide affordable insurance to 
virtually all Americans, families with insurance will not have to pay 
an extra thousand dollars a year to offset health care costs for those 
who show up at hospitals without insurance.
  Seniors will no longer fall into the doughnut hole.
  Our youth will be able to stay on their family policies until they 
are 26. And small businesses will see significant savings in health 
insurance costs because they will purchase insurance with the same 
price advantages as large businesses. And many small businesses will 
receive temporary tax credits.
  That's what is in the bill, and it is more than paid for. The CBO 
projects significant savings for the first 10 years, and huge savings 
for the next 10 years.
  Mr. Speaker, future generations will look back at the votes we cast 
today, just as today we look back at the votes on Social Security and 
Medicare. Those future generations will see that we proudly voted in 
favor of health care for all.
  Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentleman from Colorado (Mr. Lamborn).
  Mr. LAMBORN. Mr. Speaker, I rise in opposition to this flawed health 
bill.

                              {time}  2145

  Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentleman from Texas (Mr. Hall).
  Mr. HALL of Texas. Mr. Speaker, I rise in opposition to this flawed 
health care bill.
  Mr. Speaker, as we enter the most important and eventful week of the 
thirty years I've been up here--I think of the consequences of the 
votes we will cast--both Republican and Democrat.
  When we passed the health bill on this very floor--the Democrats--
with a 40 vote advantage on the House Floor--passed H.R. 3962 with a 5 
vote advantage--which showed that the outrageous health bill had been 
lessened in severity in the Commerce Committee--and was softened up 
enough for the Senate to kill it. Then, a series of Senators negotiated 
gifts they were not entitled to--each receiving a different 
consideration--into being the coveted 60th vote. If we take the Floor 
back--I would favor subpoenaing those who may have made the overtures 
to compare it to the law of bribery or corrupt deals. I would send the 
results to the Federal and State Prosecutors. The bribery penalty as 
set out in 18 U.S. Code Section 203 ``is imprisonment for not more than 
a year and a civil fine of not more than $50,000 for each violation.'' 
I consider offering a bribe--for a personal benefit--as worse than 
accepting one; let's clean up the United States Congress--and listen to 
our people whose only request is to take back our country.
  Webster's Dictionary defines ``bribe'' as money or favor given or 
promised to a person in a position of trust to influence their judgment 
or conduct.
  Mr. CAMP. Mr. Speaker, for the purpose of a unanimous consent 
request, I yield to the gentlewoman from North Carolina (Ms. Foxx).
  Ms. FOXX. Mr. Speaker, I rise in opposition to this flawed health 
bill.
  Mr. CAMP. For the purpose of a unanimous consent request, I yield to 
the gentleman from New York (Mr. King).
  Mr. KING of New York. Mr. Speaker, I rise in opposition to this 
flawed health care bill.
  Mr. CAMP. Mr. Speaker, I yield 4 minutes to the distinguished 
gentleman from Virginia (Mr. Cantor), the Republican whip.
  Mr. CANTOR. Mr. Speaker, all of us in this body, Republicans and 
Democrats alike, care about Americans' health care, but many of us from 
both sides of the aisle don't care for this trillion dollar overhaul. 
And the fact is, the majority of Americans don't care for it either.
  Sadly, Mr. Speaker, the only bipartisanship we've seen surrounding 
this overhaul has been in opposition to it, and there's a reason for 
that. Health care is a very personal issue, and this overhaul will 
impact every man, woman, and child in this country. It will even affect 
future generations that have not yet been born.
  Mr. Speaker, this overhaul will have a huge impact on our parents, 
our spouses, and our kids. This is something that they'll be paying for 
for the rest of their lives. And for too long, Mr. Speaker, the 
majority in this body and the President of the United States have 
refused to listen to the American people.
  So, Mr. Speaker, I have a message for those Americans. We hear you. 
We hear you loud and clear, because we believe this government must 
stop spending money that it doesn't have, and this trillion dollar 
overhaul will do the opposite.
  We believe that this government must stop piling debt upon our 
children and grandchildren, and this trillion dollar overhaul will do 
the opposite.
  We believe that this government must stop raising taxes on small 
businesses and families, and, Mr. Speaker, this trillion dollar 
overhaul will do the opposite.
  We believe that America is the land of innovation and that government

[[Page 4171]]

must stop crippling job creators and entrepreneurs with oppressive 
mandates and taxes, and this trillion dollar overhaul will do the 
opposite.
  Mr. Speaker, we believe that in America our government must not force 
those who fundamentally object to abortion to have to pay for it, and 
this trillion dollar overhaul does the opposite.
  And we believe in building upon what works in our current health 
care, Mr. Speaker, so that doctors in America can continue to provide 
the best care in the world, and this trillion dollar overhaul does the 
opposite.
  And, Mr. Speaker, we believe that families and patients should have 
the freedom and the right to choose the doctors they want, and this 
trillion dollar overhaul will begin to take that freedom away.
  Mr. Speaker, if there's one thing that the American people have 
learned over the past year, it's that we are truly at a critical time 
in this country. We are at a crossroads.
  This trillion dollar health care overhaul before us today has caused 
a lot of fear and uncertainty. It's the latest part of an agenda that 
is being forced upon the American people that attempts to seize more 
control over the economy and our lives.
  The choices we make on deficit spending, higher taxes, energy 
security, and health care, they're all important. They're important 
because they will all determine what kind of country we want to be.
  The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has 
expired.
  Mr. CAMP. I yield the gentleman 30 additional seconds.
  Mr. CANTOR. Mr. Speaker, the choice before us is very clear. The 
choice is whether we want to become a country that is unrecognizable, 
or one that will fulfill the American Dream so that we remain the most 
secure and most prosperous, freest country in the history of the world.
  Mr. Speaker, I urge my colleagues today to listen to the people and 
vote ``no'' against this legislation.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to Mr. Ackerman of New York.
  Mr. ACKERMAN. I rise in enthusiastic support of this historic, 
important bill.
  Mr. Speaker, I rise on this historic day in strong support of the 
Health Care and Education Affordability Reconciliation Act of 2010, 
H.R. 4872.
  Let me be perfectly clear: all Americans should have access to 
affordable and quality health-care coverage. For too long, drastically 
needed health-insurance reform has been delayed. I'm proud that the 
overdue reform of our health-care insurance system has finally begun. 
Many of us, including Members of Congress, enjoy excellent health-care 
coverage. But far too many people have inadequate coverage, including 
over 70,000 of my constituents who are completely uninsured. And for 
those of us with coverage, the status quo is unsustainable and costly: 
Without health insurance reform, the insurance premium for an average 
family is expected to rise from $13,000 today to $24,000 in less than a 
decade. Mr. Speaker, my constituents want reduced costs, more choices 
and expanded coverage.
  I support this landmark legislation because it changes the way that 
insurance companies currently ration medical care: The legislation we 
are about to pass would require all plans to eliminate coverage denials 
because of pre-existing conditions, eliminate dropping coverage when 
individuals become sick, eliminate annual and lifetime caps on how much 
can be spent on care, and eliminate exorbitant out-of-pocket expenses. 
Opponents of this bill would rather have the big health-insurance 
companies dictate the rules. But I think all Americans deserve these 
basic protections from their health-insurance plans, and these 
important guarantees will improve the coverage for nearly all those who 
already have insurance--even those Americans who are extremely 
satisfied with their current plans.
  The Act starts with what works well in today's health care system and 
fixes the parts that are broken. No one has to give up the health care 
they enjoy today--everyone can keep their current health plan, doctors 
and hospitals. New state marketplaces called exchanges will allow 
uninsured individuals to shop among a large number of private plans 
with a core set of benefits. For the first time ever, American 
families--even those who keep their current health insurance--will 
benefit from no longer having to worry about losing health coverage 
because of a new or lost job. The bill finally brings the type of 
health insurance reform that Americans need and deserve.
  Many opposed to comprehensive health insurance claim there are no 
immediate benefits to these bills; that somehow nothing happens until 
the exchanges are set up. Mr. Speaker, here are just some of the 
immediate benefits that take effect this very year: small businesses 
will receive tax credits for offering health insurance to their 
employees; seniors who fall within the infamous Medicare prescription-
drug donut hole will receive a $250 rebate; people who have been denied 
health-care coverage because of a pre-existing condition will be able 
to get affordable coverage through temporary high-risk pools; children 
will no longer be callously denied coverage because of a pre-existing 
condition; annual limits and lifetime limits on the cost of care will 
start to be prohibited; and also this year, insurance companies will no 
longer be able to take away an individual's coverage because they get 
sick.
  Mr. Speaker, unfortunately, the previous Administration and the 
former leadership of the House of Representatives never acknowledged 
the moral or economic costs we pay every day for our failure to make 
health coverage affordable and accessible for everyone. Today, that 
ends. Today we recognize that more people with good coverage saves 
lives and saves costs. Today we unequivocally state that people should 
not have to go bankrupt to pay their medical bills. And today we 
finally realize that no one should have to go to an emergency room just 
to receive routine medical care. I am proud to be voting today to make 
sure that health-care insurance reform is putting these essential 
principles into action.
  So, Mr. Speaker, I urge all my colleagues to support the Health Care 
and Education Affordability Reconciliation Act of 2010, H.R. 4872 so 
that all Americans will have access to health care.
  The SPEAKER pro tempore. The gentleman will be charged.
  Mr. SPRATT. For purposes of another unanimous consent request, I 
yield to the gentlelady from California (Ms. Waters).
  Ms. WATERS. Mr. Speaker, I rise in support of this bill.
  Our health care system is broken; no one can deny it.
  Every day, millions of Americans go without needed health care 
because they have no insurance. Some of these people work for small 
businesses and other employers that do not provide insurance. Some of 
them lost their insurance when they lost their jobs. Some of them were 
denied coverage by insurance companies because of a pre-existing 
condition. And some of them simply could not afford the escalating 
premiums. Even for people with health insurance, a devastating accident 
or illness can be very expensive. The cost of health care is the number 
one reason for bankruptcies in America.
  So we cannot afford inaction. Today, we have a clear choice--to start 
to fix the broken health care system--or to do nothing.
  However, this bill is not perfect. I would like to have seen included 
measures such as a public health insurance option like Medicare that 
would compete with the private insurance plans and a single national 
insurance exchange where people could purchase the health plan of their 
choice instead of separate state-based exchanges with different 
standards. I believe these measures would be more effective at 
containing costs and creating competition for the insurance industry.
  I am also concerned that this bill should not be used to limit the 
right of women to reproductive choice. Despite the President's 
Executive Order, attempting to codify existing law under the so-called 
Hyde Amendment, it is not clear that the Senate bill does not go beyond 
the Hyde amendment.
  Nevertheless, I have decided to support H.R. 3590, together with the 
improvements included in H.R. 4872, because it will make health care 
more affordable and more accessible for thousands of my constituents 
and millions of Americans. By passing this legislation today we are 
taking a critically important step in the right direction.
  According to an analysis by the House Energy and Commerce Committee, 
this health care reform bill will benefit California's 35th District in 
the following ways:
  Improve coverage for 281,000 residents with health insurance.
  Extend coverage to 125,500 residents who lack insurance.
  Guarantee that 21,200 residents with pre-existing conditions can 
obtain coverage.
  Allow 58,000 young adults to obtain coverage on their parents' 
insurance plans.

[[Page 4172]]

  Give tax credits and other assistance to up to 157,000 families and 
15,100 small businesses to help them afford coverage.
  Improve Medicare for 62,000 beneficiaries, including reducing the 
costs of prescription drugs and closing the donut hole.
  Protect 1,100 families from bankruptcy due to unaffordable health 
care costs.
  Provide millions of dollars in new funding for 10 community health 
centers.
  Reduce the cost of uncompensated care for hospitals and other health 
care providers by $15 million annually.
  Many provisions of the bill will kick in immediately. Insurance 
companies will no longer be able to take away a person's insurance 
because the person gets sick, an unfair practice known as rescission. 
It will immediately prevent insurance companies from denying coverage 
to children with pre-existing conditions, and eventually end 
discrimination against anyone with a pre-existing condition. It will 
immediately allow young people the ability to remain on their parents' 
insurance until age 26. It will immediately help seniors pay for 
prescription drugs and eventually eliminate the donut hole completely. 
And it will extend tax credits to small businesses so that they can 
provide health insurance to their employees.
  Over the next few years, the bill will extend coverage to 32 million 
Americans, or 95 percent of the population, providing affordability 
credits for individuals who cannot afford to purchase health insurance 
on their own.
  Improving our health care system is essential to setting us on the 
right path to healthier lives, renewed American innovation, and a 
stronger, more stable American economy. I urge my colleagues to support 
this bill and expand access to health care for families and small 
businesses throughout the United States of America.
  Mr. SPRATT. For purposes of a unanimous consent request, I yield to 
Mr. Driehaus from Ohio.
  Mr. DRIEHAUS. Mr. Speaker, I rise in support of this health care 
legislation.
  Mr. SPRATT. Mr. Speaker, I now yield 1 minute to the gentlelady from 
Minnesota (Ms. McCollum).
  Ms. McCOLLUM. Mr. Speaker, beyond the walls of this Capitol, there 
are millions of Americans who can't afford health insurance and they 
live in fear of getting sick. Millions more are discriminated against 
by insurance companies because they have preexisting medical 
conditions.
  In my own life, as a child and as an adult, I've lived without health 
insurance. A dear, dear niece of mine has a preexisting condition that 
makes her uninsurable.
  Passing health insurance reform is not a political game. It's 
personal. It's about real people's lives. When we pass this bill, we 
will save lives. Families will be protected. Millions of Americans will 
no longer live in fear.
  Today I will vote to end discrimination against people with 
preexisting conditions. Today I will vote to extend health care to 32 
million Americans. And when this bill becomes law, health care security 
will finally become a reality for the American people.
  Mr. CAMP. Mr. Speaker, at this time I will yield to the gentleman 
from California for the purpose of a unanimous consent request.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, because of 
confusion over its legal effect, I ask unanimous consent that the text 
of President Obama's Executive order referring to abortion funding, 
that it be considered as a freestanding amendment to the text of H.R. 
3590 and we be allowed to vote on it separately.
  The SPEAKER pro tempore. The Chair cannot entertain such a request 
unless it has been cleared.


                        Parliamentary Inquiries

  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, parliamentary 
inquiry.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, is such unanimous 
consent request, is it, in fact, in order under the rules of the House?
  The SPEAKER pro tempore. The Chair has indicated that requests for 
these matters must be cleared.
  The Chair is not obligated to instruct Members on the rules of the 
House.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, with respect, may I 
make a further inquiry, Mr. Speaker?
  The SPEAKER pro tempore. The gentleman may inquire.
  Mr. DANIEL E. LUNGREN of California. Would that request, if it were 
cleared, be considered germane to the bill under consideration?
  The SPEAKER pro tempore. The Chair will not respond to hypotheticals.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, additional 
parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman may proceed.
  Mr. DANIEL E. LUNGREN of California. When I am informed that it must 
be cleared, do I understand that to mean it must be cleared by the 
Speaker or the majority leader?
  The SPEAKER pro tempore. Leadership on both sides must clear these 
matters. I'm sure the gentleman knows that.
  Mr. DANIEL E. LUNGREN of California. I thank the Speaker.
  Mr. CAMP. Mr. Speaker, I reserve my time.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentlewoman from Ohio (Ms. Kaptur).
  Ms. KAPTUR. Mr. Speaker, I rise in support of affordable health 
insurance for all Americans.
  I rise in support of this historic legislation because affordable 
health care is really about life--about a healthier and more secure 
life for all Americans.
  This is about life--the life of a senior who can't afford 
prescription drugs, or a mother carrying a new life waiting to be born.
  This legislation says every American has the right to the dignity of 
a healthy life. Nothing more, nothing less. Its promise is true for all 
citizens, of all ages, from all walks of life. In that respect, it is 
profoundly American.
  It is most certainly about the millions of citizens in our nation who 
run small businesses and about their employees--who after all these 
years comprise over half the uninsured in our nation. These businesses 
embody the hopes and dreams of life in America. They are the engines of 
job growth, but after all these decades, they are treated like second 
class citizens.
  This bill is about women and children--the millions of women who have 
no health care and the millions of children who are born frail and weak 
because their mothers have no access to prenatal care and their fathers 
have no insurance. The March of Dimes tells us that every year, more 
than half a million American children are born underweight, one out of 
every eight children born premature, malnourished, and so many with 
disability. That should not happen in America. Our nation's insurance 
programs aren't meeting the market nor the promise of America.
  This legislation will help millions of women obtain health coverage 
and thus reduce abortion by enhancing broad coverage options for 
women's and children's health. It will vastly improve preventive care, 
more than double funds available to community health centers (including 
obstetric and gynecological care), and move America fully into this 
21st century. No woman, no woman--including poor women, pregnant women, 
working women, single women, and nursing women--will be denied health 
insurance coverage.
  Mr. Speaker, the best anti-abortion bill we can pass is one that 
gives women and children a real chance through health insurance 
coverage that allows fragile life to come to term. This bill does that. 
It gives hope, to every family, to every woman to every child yet to be 
born. It says you have a right to be born. It provides for prenatal 
care during a woman's pregnancy, preventive care for newborns, funding 
to help pregnant and parenting teens and college students with 
assistance for basic necessities, as well as adoption tax credits. No 
family, no mother, no father will ever have to question again whether 
they can afford to bring a conceived child to term
  This bill is about a better life for seniors, too. By closing the 
doughnut hole, it makes sure they can afford the medicine they need to 
live healthy, independent lives.
  As the costs of insurance have risen, emptying the wallets of our 
neighbors, almost one in three Americans (87 million of our fellow 
citizens) went without health insurance for some period last year. We 
can do better in America.
  There is so much shifting in the marketplace, it is becoming less 
stable and reliable. Thousands more of our citizens are losing their 
insurance because they have lost their jobs as the unemployment 
epidemic rages throughout our nation.
  Even those with insurance, no matter how expensive or robust it might 
be, learn their

[[Page 4173]]

coverage is not guaranteed nor continuous nor quality. Millions of 
hardworking Americans are denied coverage; charged an impossibly higher 
rate, or discriminated against because of a pre-existing condition. 
Family employer-sponsored health insurance increased 119 percent over 
the last decade. Small business premiums alone have risen 129 percent. 
Without reform, rates are projected to increase to $23,842 on average 
by 2020. This simply cannot continue; the system is broken.
  I can identify with the tens of millions of our fellow citizens who 
have no health insurance, over half of whom are either small business 
owners or their employees. When my brother, Steve, and I were growing 
up, our beloved, hardworking father, ``Kappy,'' had three heart 
attacks. He made the gut-wrenching decision to sell our small family 
market to go to work in an auto plant for one reason: to get health 
insurance for his wife, Anastasia, and their two children. He didn't 
even care about himself. I shall never forget that piercing experience: 
it is the story of millions upon millions of our fellow citizens 
excluded, priced out or eliminated from the insurance market place. In 
our parents' memory, the best jobs bill I can vote is one that takes 
the health insurance anxiety off the backs of small businesspeople 
across our nation. I do so today in our parents' memory.
  I have listened closely to the concerns of citizens in Ohio's Ninth 
Congressional District. There is passion on both sides. Some claim this 
legislation is unconstitutional. I respectfully disagree. To accept 
that argument is to say that Social Security is unconstitutional, or 
Medicare is unconstitutional, or veterans' benefits are 
unconstitutional, or the interstate highway system is unconstitutional. 
I believe that argument would tear apart the fabric of our Republic.
  Affordable health insurance reform is necessary to provide greater 
competition among available plans to cut the costs of doing business, 
reduce the share of government expenditures spent on health care, help 
our companies to be more competitive in the world market, unleash the 
entrepreneurial talents of the American people, and give peace of mind 
to the middle class, our seniors and others that everything they have 
worked for will not be taken away if they get sick.
  I have been touched by stories from constituents and I rise today in 
support of this historic bill for them:
  David owns a small business. In 1999, he offered health insurance to 
his 15 employees. Over the course of the next decade, his insurance 
premiums skyrocketed and he had to let some employees go. By 2007 he 
was down to three employees and could no longer provide insurance for 
them--or himself. Now uninsured, he recently suffered a heart attack. 
Health care expenses forced him to file for bankruptcy. Sad to say, his 
case is not all that unusual--health care costs are the leading cause 
of bankruptcy in America.
  Jeff changed jobs and was required to obtain different health 
insurance while his wife was mid-term in a pregnancy. The pregnancy was 
high risk, the birth was problematic, and the insurer, a ``health 
maintenance organization,'' an HMO, denied coverage not only for the 
mother's labor and delivery, but also their baby's conditions at birth.
  Lillian will reach her allowable Part D private drug plan coverage in 
March. She cannot afford to pay for her medicines, so she never climbs 
out of the ``doughnut hole'' to obtain coverage again. As a result, she 
will quit taking her prescription drugs for nine months, until the new 
year starts. As a result, she has been hospitalized.
  Mary has suffered from bipolar disorder since her twenties. She is 
now in her fifties. She is married, with a family. She has experienced 
many exacerbations of her illness and resulting hospitalizations. She 
reached the insurer's lifetime maximum when in her early forties. Since 
then, her family has had to pay her expenses.
  Susan is the director of a nonprofit organization that serves 
homeless families. The organization offers health insurance to 
employees, but the premium increase this year was 49%. Now the agency 
must choose between dropping insurance as an employee benefit or 
reducing services to the vulnerable families it serves. Meanwhile, the 
insurer posted record profits last year.
  Bob and Catherine were married for 53 years and raised six children. 
Catherine developed a chronic debilitating illness which worsened over 
time. Bob took care of her at home for nine years, using all of their 
savings and having to sell their house.
  Cassandra is a12-year-old girl with juvenile diabetes. Since her 
diagnosis as a toddler, her parents have been unable to obtain health 
care coverage even though they could afford to pay for it. They must 
pay all her health expenses out of pocket. They live in a small 
apartment.
  Aaron is 14. He has a failing liver and has needed a liver transplant 
for five years. His mom could not work because she had to care for him. 
The family has no health care coverage. Though the hospital absorbed 
much of the cost for his care and treatment, the family held 
fundraisers through the years to pay for his transplant and the health 
care which has subsequently followed. All of us are familiar with the 
spaghetti dinners, and benefit dances, and silent auctions to help 
families in similar circumstances. Heroic compassionate people rise to 
the occasion in communities across our nation, but often it simply is 
not enough.
  For too long, the health of our nation has dwindled--indeed the U.S. 
ranks behind over a dozen major nations in health outcomes--while the 
pockets of the insurance giants have thickened. Insurance companies 
raise rates and deny coverage to pay their CEOs excessive salaries and 
bonuses. WellCare and Aetna's executives, for example, received between 
$18 and $23 million dollars alone in 2008. Despite wanting to increase 
premiums recently for individuals by 39 percent, WellPoint's 
executives, which is an insurance provider in the state of Ohio where I 
represent, received over $8.6 million.
  Our seniors have compromised prescription drugs for necessary 
groceries, while the insurance and pharmaceutical industries have made 
record profits. Hard working families have watched their savings 
plummet and their homes foreclosed after unexpected illnesses. Women 
with breast cancer, men with heart disease and children with leukemia 
or childhood diabetes have been flat-out denied health insurance 
coverage for pre-existing conditions or reaching insurance policy caps.
  With the mounting economic strain on American families and the rising 
costs of health insurance to workers, businesses and the federal 
budget, the status quo has proven itself unsustainable, fiscally 
irresponsible and morally unacceptable. The time has come for this 
historical change. The bill before us pays for itself and actually 
brings revenues back to the health system as a result of the 
combination of added competition and better use of the health dollar. I 
stand in support of its promise to the American people--the promise of 
a better and healthier life for all in this blessed land.
  Mr. SPRATT. Also for purposes of a unanimous consent request, I yield 
to Mrs. Dahlkemper from Pennsylvania.
  Mrs. DAHLKEMPER. Mr. Speaker, I rise in support of this health care 
legislation.
  Mr. SPRATT. I now yield 1\1/2\ minutes to the gentlewoman from 
Connecticut (Ms. DeLauro).
  Ms. DeLAURO. Mr. Speaker, I rise in support of this historic 
legislation, arguably the most important vote we here today will ever 
take in this Chamber.
  Today fulfills a promise made 100 years ago by Theodore Roosevelt 
when he first called for comprehensive health insurance reform. It 
fulfills a promise made by Franklin Roosevelt to our parents, our 
grandparents, our great-grandparents in 1944. President Richard Nixon 
also labored and lost on this national mission. And President Bill 
Clinton, too, tried to climb this mountain.
  Today's legislation builds on the great achievements of Social 
Security and Medicare, those big changes that we all take for granted, 
regardless of party. And yes, they, too, were characterized as 
socialist government takeovers.
  And today we have a chance to make health insurance affordable for 
people and for small businesses that ends the power of the insurance 
companies to deny them coverage, increase their rates and, yes, drop 
them when they get sick. Enough.
  This reform law allows 32 million of our citizens to get insurance, a 
moral imperative. It closes the doughnut hole in prescription drugs for 
seniors, and women will no longer have to pay more for their insurance, 
a long overdue reckoning.
  I am humbled by the opportunity to cast a vote for this historic 
change.
  Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
  We've heard a lot of discussion tonight about this bill and how it's 
been characterized. Let me just read a few quotes from my friends on 
the Democratic side who've characterized this bill.
  A Democrat from North Carolina says: There is no question that our 
current health care system is broken and

[[Page 4174]]

that we need to make significant reforms to improve it in an equitable, 
fiscally responsible, and sustainable manner. In my opinion, the bill 
as written does not meet those criteria.
  A Democrat from Tennessee says: After thorough and careful review of 
the legislation, I am unconvinced that the long-term trend of rising 
health care costs is adequately addressed and am, therefore, unable to 
support the legislation.
  A Democrat from New Mexico said: I do not believe that the bill does 
enough to contain costs.
  A Democrat from North Carolina says: Health care reform is needed, 
but the bill before us is too expensive, does not adequately address 
rising medical costs and skyrocketing insurance premiums, and tries to 
do too much too soon. We simply cannot afford to create a new Federal 
bureaucracy that costs nearly $1 trillion when our national debt is $12 
trillion and there is no plan in place to address it. I will not vote 
for it.
  Another Democrat from Virginia says: I have spoken with countless 
small business owners, families, medical professionals, and average 
citizens across Virginia, and it becomes very clear that this bill is 
not the right solution for Virginia's health care challenges.
  On and on and on again. This is not the right bill for America. This 
costs $1 trillion, raises a half a trillion in taxes, and cuts Medicare 
by half a trillion dollars. Vote ``no'' on this bill.

                              {time}  2200

  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentlelady from New York (Mrs. Lowey).
  Mrs. LOWEY. I rise in strong support of this bill.
  Mr. Speaker, I rise in support of enacting historic health care 
reform.
  Over the past fifteen months, I have held countless meetings with 
community organizations, small business owners, senior citizens, 
doctors, nurses, and patients, joined public forums and community 
meetings, and held telephone town halls. It is clear to me the status 
quo is unsustainable. Without action, individuals would continue to be 
denied coverage and care, more families would go into bankruptcy due to 
the costs of care, and businesses would continue to struggle to cover 
their employees.
  Some benefits will be evident almost immediately after this bill is 
signed. The most egregious practices of insurance companies, like 
denying coverage for children due to pre-existing conditions and 
dropping coverage when patients become sick, will be illegal. Small 
businesses will gain tax credits to provide affordable insurance to 
their employees. Senior citizens will benefit from immediate steps to 
close the Medicare prescription drug ``donut hole.''
  I have heard hundreds of personal stories. A social worker in Ardsley 
earning $53,000 per year whose out-of-pocket insurance premium just 
increased by $110 to $831 per month. Or the man from White Plains who 
was denied life saving cancer medication by his insurance company until 
my intervention. The small business owner from Ossining whose premium 
costs increased 40 percent this year.
  I want to assure you that:
  Medicare benefits will be strengthened by closing the prescription 
drug ``donut hole,'' eliminating charges for preventive care, and 
extending the solvency of the Medicare Trust Fund.
  The vast majority of families in Westchester and Rockland Counties 
will see absolutely no change in their income taxes due to this bill. I 
fought to protect our region, and I continue my work to index federal 
taxes to cost of living, which would help residents in our expensive 
area.
  Small businesses with fewer than 50 employees are exempt from 
employer requirements and some will immediately be offered tax credits 
to provide coverage for their employees.
  This legislation will not provide taxpayer funding for abortion, and 
in fact I am not pleased with new obstacles to reproductive health 
care.
  And finally, this bill will reduce the federal deficit by more than 
$143 billion in the first ten years and more than $1.2 trillion in the 
second ten years after passage.
  Instead of passing the House bill, the Senate adopted a flawed bill 
that I will support for the sole purpose of immediately making 
improvements through reconciliation to help American families and 
businesses.
  Although the legislation we passed this week is not perfect, it will 
rein in skyrocketing insurance premiums for families, prevent the worst 
practices of the insurance industry, help 30 million uninsured 
Americans gain access to care, allow insured Americans to keep their 
coverage if they like it, help small businesses afford coverage for 
their employees, allow children up to 26 years old to stay on their 
parents' plans and protect Medicare for senior citizens.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from New Jersey (Mr. Payne).
  Mr. PAYNE. Mr. Speaker, I rise in support of this great health care 
reform bill.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from Florida (Mr. Grayson).
  Mr. GRAYSON. I rise in support of this bill.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from Georgia (Mr. Bishop).
  Mr. BISHOP of Georgia. I rise in support of this historic health care 
reform bill.
  Mr. Speaker, I have decided to support the health reform legislation 
because it represents an historic opportunity to make health care more 
accessible and affordable now and into the future. I base this decision 
not on what is popular, but on what I believe is in the best interest 
for Georgia's Second Congressional District both in the short- and 
long-term.
  Throughout this process, I have solicited the views of people both 
supporting and opposing health care reform. I have heard from doctors 
and patients, small business owners and the CEOs of large corporations, 
as well as residents of rural and urban areas. I also have heard from 
the healthy and the sick, the young and the old, and the rich and the 
poor. I thank each of you who shared your views with me, and I have 
listened to your opinions.
  In my district there are more than 83,000 uninsured residents who 
will receive health insurance coverage under this bill. There are 
14,500 uninsured individuals who have a pre-existing medical condition 
such as cancer, heart disease, and diabetes and who will now no longer 
be denied affordable health insurance coverage. In addition, there are 
12,100 small business owners in my district who will qualify for tax 
credits to help employees afford health care.
  My district is also home to 96,000 senior citizens who will benefit 
from a stronger Medicare program whose solvency is extended to 2026. 
There are 6,600 Medicare beneficiaries who will now be able to afford 
their prescription drugs with the closure of the Part D 'donut hole.' 
And, through the health care reform bill, 181,000 households in 
Southwest Georgia could qualify for tax credits to purchase health 
insurance through Medicaid, employer sponsored insurance, or other 
acceptable coverage. For these people and for millions of Americans 
like them, I have decided to support the health care reform bill.
  Some people have asked how I could be a fiscally conservative Blue 
Dog Democrat and still support the health reform bill. I do not know 
how I could be a Blue Dog Democrat and not support this bill. According 
to the nonpartisan Congressional Budget Office, the bill will reduce 
the deficit by $138 billion over the next 10 years and $1.2 trillion in 
the decade after that. It includes tough provisions attacking waste and 
fraud in the Medicare and Medicaid programs, including some proposed by 
Republicans. It will slow the growth in health care costs that are 
becoming an increasing burden on families, businesses, and governments. 
And the legislation will benefit rural America by boosting mandatory 
funding for community health centers by $11 billion over five years and 
making significant investments in the training of primary care doctors.
  This bill is not perfect. We cannot, however, let the perfect be the 
enemy of the good. Nor can we allow fear, misinformation, political 
motivation and partisanship to prevent us from taking the necessary 
steps to improve our health care system. I believe that we have a moral 
obligation to ensure that all Americans, regardless of race, ethnicity, 
geography, or income, receive the health care they need to lead healthy 
and productive lives.
  As a man of faith, I know that Jesus taught us to provide and care 
for others, especially the `least of these' who often have few 
advocates. In addition, when I ask myself, `What would Jesus do if he 
represented the Second Congressional district, and had the opportunity 
to vote to enable more than 32 million uninsured Americans to receive 
health insurance?'

[[Page 4175]]

I believe He would take care of this immediate need of the people--not 
let them fend for themselves while we start over or do nothing. This 
legislation goes a long way toward living up to this moral principle, 
and I am proud to support it.
  Mr. SPRATT. Mr. Speaker, can you tell me how much time is remaining 
on my side?
  The SPEAKER pro tempore. There are 2\1/4\ minutes remaining for the 
gentleman from South Carolina.
  Mr. SPRATT. Mr. Speaker, I yield 1\1/4\ minutes to the gentleman from 
New Jersey (Mr. Andrews).
  Mr. ANDREWS. Mr. Speaker, our friends on the other side of the aisle 
have asked frequently tonight what kind of country are we. They've 
asked exactly the right question. Tomorrow when a person is denied a 
job because she has breast cancer or is charged higher premiums because 
he has asthma, what kind of country will we be? Tomorrow when a senior 
citizen has enough money in her checking account to pay the utility 
bill or her prescription bill but not both, what kind of country will 
we be? When a person who tonight is scrubbing floors or pumping gas or 
waiting on tables tomorrow tries to go to buy a health insurance policy 
for herself or her children, what kind of country will we be?
  For Social Security, we gave decency for seniors. In Medicare, we 
gave compassion for seniors. In the Civil Rights Act, we gave equality 
for all Americans. Tonight, we will give justice and decency. That's 
the kind of country that we will be.
  Mr. CAMP. Mr. Speaker, at this time I yield 1 minute to the 
distinguished minority leader, the gentleman from Ohio (Mr. Boehner).
  Mr. BOEHNER. Mr. Speaker and my colleagues, I rise tonight with a sad 
and heavy heart. Today we should be standing together reflecting on a 
year of bipartisanship and working to answer our country's call and 
their challenge to address the rising costs of health insurance in our 
country.
  Today, this body, this institution, enshrined in the first article of 
the Constitution by our Founding Fathers as a sign of the importance 
they placed on this House, should be looking with pride on this 
legislation and our work.
  But it is not so.
  No, today we're standing here looking at a health care bill that no 
one in this body believes is satisfactory. Today we stand here amidst 
the wreckage of what was once the respect and honor that this House was 
held in by our fellow citizens. And we all know why it is so. We have 
failed to listen to America. And we have failed to reflect the will of 
our constituents. And when we fail to reflect that will, we fail 
ourselves, and we fail our country.
  Look at this bill. Ask yourself, do you really believe that if you 
like the health plan that you have that you can keep it? No, you can't. 
You can't say that.
  In this economy, with this unemployment, with our desperate need for 
jobs and economic growth, is this really the time to raise taxes, to 
create bureaucracies, and burden every job creator in our land? The 
answer is no.
  Can you go home and tell your senior citizens that these cuts in 
Medicare will not limit their access to doctors or further weaken the 
program instead of strengthening it? No, you cannot.
  Can you go home and tell your constituents with confidence that this 
bill respects the sanctity of all human life and that it won't allow 
for taxpayer funding of abortions for the first time in 30 years? No, 
you cannot.
  And look at how this bill was written. Can you say it was done 
openly, with transparency and accountability? Without backroom deals 
and struck behind closed doors hidden from the people? Hell, no, you 
can't.
  Have you read the bill? Have you read the reconciliation bill? Have 
you read the manager' s amendment? Hell, no, you haven't.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Both sides would do well to remember the 
dignity of the House.
  Mr. BOEHNER. Mr. Speaker, in a few minutes we will cast some of the 
most consequential votes that any of us will ever cast in this Chamber. 
The decision we make will affect every man, woman, and child in this 
Nation for generations to come. If we're going to vote to defy the will 
of the American people, then we ought to have the courage to stand 
before them and announce our votes, one at a time.
  I sent a letter to the Speaker this week asking that the ``call of 
the roll'' be ordered for this vote. Madam Speaker, I ask you, will 
you, in the interest of this institution, grant my request?
  Will you, Mr. Speaker, grant my request that we have a call of the 
roll?
  The SPEAKER pro tempore. Is the gentleman asking a rhetorical 
question?
  Mr. BOEHNER. Mr. Speaker, will you grant my request that we have a 
call of the roll?
  The SPEAKER pro tempore. Under clause 2(a) of rule XX, a record vote 
is conducted by electronic device unless the Speaker directs otherwise.
  MR. BOEHNER. And you, Mr. Speaker, will you grant that request?
  The SPEAKER pro tempore. The Chair will decide at the time the 
question is ripe. This is not it.
  Mr. BOEHNER. My colleagues, this is the People's House.
  When we came here, we each swore an oath to uphold and abide by the 
Constitution as representatives of the people. But the process here is 
broken. The institution is broken. And as a result, this bill is not 
what the American people need nor what our constituents want.
  Americans are out there making sacrifices and struggling to make a 
better future for their kids, and over the last year as the damn-the-
torpedoes outline of this legislation became more clear, millions of 
Americans lifted their voices and many, for the first time, asking us 
to slow down, not to try to cram through more than this system could 
handle, not to spend money that we didn't have. In this time of 
recession, they wanted us to focus on jobs, not more spending, not more 
government, and certainly not more taxes.
  But what they see today frightens them. They're frightened because 
they don't know what comes next. They're disgusted because what they 
see is one political party closing out the other from what should be a 
national solution. And they're angry. They're angry that no matter how 
they engage in this debate, this body moves forward against their will.
  Shame on us. Shame on this body. Shame on each and every one of you 
who substitutes your will and your desires above those of your fellow 
countrymen.
  Around this Chamber, looking upon us are the lawgivers from Moses, to 
Gaius, to Blackstone, to Thomas Jefferson. By our actions today, we 
disgrace their values. We break the ties of history in this Chamber. We 
break our trust with America.
  When I handed the Speaker the gavel in 2007, I said this: ``This is 
the People's House. And the moment a majority forgets it, it starts 
writing itself a ticket to minority status.''
  If we pass this bill, there will be no turning back. It will be the 
last straw for the American people. In a democracy, you can only ignore 
the will of the people for so long and get away with it. And if we defy 
the will of our fellow citizens and pass this bill, we're going to be 
held to account by those who have placed us in their trust. We will 
have shattered those bonds of trust.
  I beg you, I beg each and every one of you on both sides of the 
aisle: Do not further strike at the heart of this country and this 
institution with arrogance, for surely you will not strike with 
impunity.
  I ask each of you to vow to never let this happen again--this 
process, this defiance of our citizens. It's not too late to begin to 
restore the bonds of trust with our Nation and return comity to this 
institution.
  And so join me. Join me in voting against this bill so that we can 
come together, together anew and addressing the challenge of health 
care in a manner that brings credit to this body and brings credit to 
the ideals of this Nation, and most importantly, that reflects the will 
of the American people.

                              {time}  2215

  Mr. SPRATT. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California, who has led the way in this

[[Page 4176]]

quest for health care reform and tirelessly, persistently, she has 
brought us to this moment of the decision, the gentlewoman from 
California, the Speaker of the House, Ms. Pelosi.
  Ms. PELOSI. Thank you, my colleagues. I thank the gentleman for 
yielding. I thank all of you for bringing us to this moment.
  Mr. Speaker, it is with great humility and with great pride that 
tonight we will make history for our country and progress for the 
American people. Just think, we will be joining those who established 
Social Security, Medicare, and now tonight health care for all 
Americans.
  In doing so, we will honor the vows of our Founders, who, in the 
Declaration of Independence, said that we are endowed by our Creator 
with certain inalienable rights and among these are life, liberty, and 
the pursuit of happiness.
  This legislation will lead to healthier lives, more liberty to pursue 
hopes and dreams and happiness for the American people. This is an 
American proposal that honors the traditions of our country.
  We would not be here tonight for sure without the extraordinary 
leadership and vision of President Barack Obama. We thank him for his 
unwavering commitment to health care for all Americans. This began over 
a year ago under his leadership in the American Recovery and 
Reinvestment Act where we had very significant investments in science, 
technology, and innovation for health care reform.
  It continued in the President's budget a few months later, a budget 
which was a statement of our national values, which allocated resources 
that were part of our value system and in a way that stabilized our 
economy, created jobs, lowered taxes for the middle class and did so 
and reduced the deficit and did so in a way that had pillars of 
investment, including education and health care reform.
  Health care reform and education equal opportunity for the American 
people. This legislation tonight, if I had one word to describe it, 
would be opportunity with its investments in education and health care 
as a continuation of the President's budget.
  We all know, and it's been said over and over again, that our economy 
needs something new, a jolt, and I believe that this legislation will 
unleash tremendous entrepreneurial power into our economy. Imagine a 
society and an economy where a person could change jobs without losing 
health insurance, where they could be self-employed or start a small 
business.
  Imagine an economy where people could follow their passions and their 
talent without having to worry that their children would not have 
health insurance, that if they had a child with diabetes who was 
bipolar or preexisting medical condition in their family, that they 
would be job locked. Under this bill, their entrepreneurial spirit will 
be unleashed.
  We all know that the present health care system and health insurance 
system in our country is unsustainable. We simply cannot afford it. It 
doesn't work for enough people in terms of delivery of service, and it 
is bankrupting the country with the upward spiral of increasing medical 
cost. The best action that we can take on behalf of America's family 
budgets and on behalf of the Federal budget is to pass health care 
reform.
  The best action we can take to strengthen Medicare and improve care 
and benefits for our seniors is to pass this legislation tonight, pass 
health care reform. The best action we can do to create jobs and 
strengthen our economic security is pass health care reform.
  The best action we can take to keep America competitive, ignite 
innovation, again, unleash entrepreneurial spirit is to pass health 
care reform.
  With this action tonight, with this health care reform, 32 million 
more Americans will have health care insurance and those who have 
insurance now will be spared of being at the mercy of the health 
insurance industry with their obscene increases in premiums, their 
rescinding of policies at the time of illness, their cutting off of 
policies even if you have been fully paying but become sick. The list 
goes on and on about the health care reforms that are in this 
legislation: insure 32 million more people, make it more affordable for 
the middle class, end insurance company discrimination on preexisting 
conditions, improve care and benefits under Medicare and extending 
Medicare solvency for almost a decade, creating a healthier America 
through prevention, through wellness and innovation, create 4 million 
jobs in the life of the bill and doing all of that by saving the 
taxpayer $1.3 trillion.
  Another Speaker, Tip O'Neill, once said, All politics is local. I say 
tonight that when it comes to health care for all Americans, all 
politics is personal. It's personal for the family that wrote to me, 
who had to choose between buying groceries and seeing a doctor. It's 
personal to the family that was refused coverage because their child 
had a preexisting condition, no coverage, the child got worse, sicker.
  It's personal for women. After we pass this bill, being a woman will 
no longer be a preexisting medical condition.
  It's personal for the senior gentleman whom I met in Michigan who 
told me about his wife who had been bedridden for 16 years. He told me 
he didn't know how he was going to be able to pay his medical bills. As 
I said to you before, I saw a grown man cry. He was worried that he 
might lose his home, that they might lose their home because of his 
medical bills and he didn't know how he was going to pay them and, most 
of all, he was too embarrassed to tell his children and ask them for 
help. How many times have you heard a story like that?
  It's personal for millions of families who have gone into bankruptcy 
under the weight of rising health care costs, and so many, many, many--
a high percentage of the bankruptcy in our country--are caused by 
medical bills that people cannot pay. It's personal for 45,000 
Americans and families who have lost a loved one each year because they 
didn't and couldn't get health insurance.
  That is why we are proud and also humble today to act with the 
support of millions of Americans who recognize the urgency of passing 
health care reform and more than 350 organizations representing 
Americans of every age, every background, every part of the country who 
have endorsed this legislation. Our coalition ranges from AARP who said 
that our legislation ``improves efforts to crack down on fraud and 
waste in Medicare, strengthening the program for today's seniors and 
future generations.'' I repeat: ``improves efforts to crack down on 
fraud and waste in Medicare, strengthening the program for today's 
seniors and future generations.''
  To the American Medical Association, the Catholic Health Association, 
the United Methodist Church and Voices for America's Children, from A 
to Z, they are sending a clear message to Members of Congress, say 
``yes'' to health care reform.
  We have also reached this historic moment because of the 
extraordinary leadership and hard work and dedication of all of the 
Members of Congress, but I want to especially recognize our esteemed 
Chairs, Mr. Waxman, Mr. Rangel, Mr. Levin, Mr. Miller, Mr. Spratt, Ms. 
Slaughter, for bringing this bill to the floor today. Let us 
acknowledge them.
  I want to acknowledge the staff of the committees and of the 
leadership. They have done a remarkable job, dazzling us with their 
knowledge and their know-how.
  I would like to thank on my own staff Amy Rosenbaum, Wendell Primus 
and Arshi Siddiqui.
  Now I will close by saying it wouldn't be possible to talk about 
health care without acknowledging the great leadership of Senator 
Edward Kennedy, who made health care his life's work. In a letter to 
President Obama before he passed away--he left a letter to be read 
after he died--Senator Kennedy wrote that access to health care was 
``the great unfinished business of our society.'' That is, until today.
  After more than a year of debate and, by the way, the legislation 
that will go forth from here has over 200 Republican

[[Page 4177]]

amendments, and while it may not get Republican votes and be bipartisan 
in that respect, it is bipartisan in having over 200 Republican 
amendments.
  After a year of debate and hearing the calls of millions of 
Americans, we have come to this historic moment. Today we have the 
opportunity to complete the great unfinished business of our society 
and pass health insurance reform for all Americans. That is a right and 
not a privilege.
  In that same letter to the President, Senator Kennedy wrote, What is 
at stake? He said at stake are not just the details of policy, but the 
character of our country. Americans will look back on this day as one 
in which we honored the character of our country and honored our 
commitment to our Nation's Founders for a commitment to life, liberty 
and the pursuit of happiness.
  As our colleague, John Lewis, has said, we may not have chosen the 
time, but the time has chosen us. We have been given this country, an 
opportunity to stay right up there with, again, Social Security, 
Medicare, health care for all Americans.
  I urge my colleagues to join together in passing health insurance 
reform, making history and restoring the American Dream. I urge an 
``aye'' vote.

                              {time}  2230


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will again remind all persons in 
the gallery that they are here as guests of the House, and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. AL GREEN of Texas. Mr. Speaker, I am proud to support H.R. 4872, 
the Reconciliation Act of 2010 and the healthcare reform package that 
its passage will complete.
  Today, the House of Representatives has been given the opportunity to 
take a concrete and powerful step toward completing the work of 
reforming our healthcare system that began decades ago. For much of the 
last year, my colleagues and I have debated many ways in which we could 
work to lower costs, improve the quality of care and expand coverage. 
What we pass today will begin to achieve all three.
  In the wake of the financial crisis that has devastated our economy, 
concerns of our nation's deficit are well-placed and wholly 
appropriate. Despite what many of its opponents would argue, the 
passage of this healthcare reform package will reduce the national 
deficit by an estimated $1.3 trillion over the next 20 years according 
to the Congressional Budget Office.
  Through the course of this debate, we have seen misinformation about 
healthcare reform instill fear into the hearts of the American people. 
We have seen the distortion of truth breed uncertainty about whether 
healthcare reform will be to the benefit of our country. Despite all of 
the debate, and at times confusion, there remains one incontrovertible 
truth: the cost of inaction, when our country spends nearly $2.5 
trillion a year on healthcare, over 45 million Americans are without 
health insurance, and 45,000 people die every year due to lack of 
health insurance, is simply too great.
  The time for debate has ended. The question we are faced with is 
quite simple: do we act to shift the course of this country towards 
affordable, quality healthcare, or do we continue down the path of 
unsustainable costs and squander this historic opportunity to bring 
about meaningful change in the lives of the American people?
  I am proud to vote in favor of this giant step toward putting 
Americans in control of their health care and I look forward to this 
legislation being signed into law so that we may move forward with this 
much needed reform.
  Mr. SMITH of Texas. Mr. Speaker, Republicans and Democrats agree on 
the need for health insurance to cover those who cannot afford it. But 
this legislation is the wrong way.
  The health care bill is built on the shifting sands of higher 
premiums, increased taxes and reduced benefits. Such a foundation 
cannot last and will be washed away by the American people in the 
November election.
  A majority of the American people want to choose their own health 
care plan, not have the government do it for them. Under this bill, 
many health care decisions will be made by federal employees, not 
patients and their doctors. The result will be less care at higher 
cost.
  Mr. PUTNAM. Mr. Speaker, at the end of this term, I will have served 
in Congress for 10 years. I have had the privilege of participating in 
countless debates--from war resolutions and trade policies to the 
aftermath of the 9/11 attacks--and working with Members of Congress on 
both sides of the aisle on some of America's greatest challenges.
  We now stand on the floor of the House of Representatives to address 
one of today's greatest challenges in America--healthcare reform. While 
this may be one of the more complicated issues we are faced with, the 
goals--in my mind--are simple. We need to lower the cost of healthcare, 
while expanding healthcare coverage to more individuals. To accomplish 
this, I have advocated for policies like allowing small businesses to 
pool together and form association health plans, providing incentives 
for wellness programs and healthy life decisions, making reforms to our 
medical malpractice laws, and allowing individuals to purchase 
insurance across state lines. These policies are far-reaching, free-
market based, and--most of all--don't require new government 
bureaucracies. Unfortunately, they all lost out to a partisan process 
of backroom deals that have tainted this proposal and further 
undermined the already low esteem in which the people we serve hold in 
this institution.
  Ever since the first 2,000 page healthcare bill was dropped on my 
desk just prior to the vote in November, I have listened to 
Floridians--from parents and patients to doctors and seniors--who 
understand that healthcare is just too dynamic to be taken over by a 
stale, cold federal government. They understand that we don't need to 
model our healthcare system on those systems across the globe who envy 
our quality of care, technology, and research investment. We don't need 
some agency to make decisions about our family's healthcare that has 
the efficiency of FEMA and the compassion of the drivers license 
office. While we do have some aspects of our system that need to be 
improved, Floridians understand we should address them in a manner that 
actually solves the problem--not having government destroy the 
innovation that comes from competition. Madam Speaker, they understand 
this, but Congress clearly doesn't.
  The misguided policies we are voting on today are sadly coupled with 
the broken process they followed to get here. The measure we will vote 
on hasn't seen a single legislative committee, bi-partisan negotiation, 
or open process. Like anything with such an impact to the American 
people, this legislation deserves the scrutiny of the legislative 
process and the challenges that may come with amendments and committee 
debate. In short, this measure deserves a public vetting to arrive at 
the best possible outcome.
  Had our founders seen the process this healthcare debate has taken, 
they simply would not have recognized it as the House of 
Representatives they envisioned. Would they have supported a process 
that didn't even include the committees responsible for healthcare? 
Would they have appreciated gimmicks that only budget analysts would 
understand in order to ensure a certain overall cost? Could they 
explain why a student loan bill was mysteriously attached to a massive 
healthcare reform proposal or why Congress decided to give one state a 
better deal than the rest of the country? Could they have ever imagined 
a Congress that is only willing to dedicate two hours of debate to a 
measure that spends $1 trillion?
  Our schoolchildren are taught the way an idea becomes law and that as 
an elected Representative, I have the ability to amend this legislation 
on their behalf and spend days debating every provision that may have 
been included. They know they deserve a process that allows their 
representative to have a seat at the drafting table, not one where the 
bill is dropped on his desk just prior to a vote. Even the most casual 
observer of this process and this bill's journey would find it 
unrecognizable from our most basic understanding of civics and 
representative democracy.
  When the outcome of this vote became more important than the product 
itself, taxpayers lost. When the legislative process became an 
afterthought to salvaging a presidency, taxpayers lost. When debate was 
sacrificed for special deals, taxpayers lost.
  Madam Speaker, this process is a disservice and has birthed a flawed 
product that restrains patient freedom and choice, burdens future 
generations with debt, undermines a competitive business model for 
medicine and, most tragically, will reduce the most innovative 
diagnostics and treatment on Earth to the lowest common bureaucratic 
denominator.
  Time and again, the government proves inefficient and obsolete in 
changing times with rapidly emerging technologies. In medicine, that is 
a recipe for obsolescence, archaic approaches, and delayed treatments 
that costs lives and weakens the human condition.

[[Page 4178]]

  While I do not hold up the current health care model as perfect--I do 
observe the quality of the treatment options, the daily miracles made 
possible by world-class technology guided by well-trained health care 
professionals, and the range of options in large and small towns alike 
as evidence that the American model is far superior to the cumbersome, 
one-size-fits-all models that are found in nations like Canada and the 
UK whose citizens frequently flee to our nation to find the quality 
care they believe is not available in their own countries.
  Tonight's vote against this bill is cast on behalf of patients and 
doctors, taxpayers and citizens who value innovation, competition, and 
the spirit of the individual that has created the American experience 
and built this great nation into the envy of the world.
  While we can and must do more to improve access and affordability, we 
shouldn't sacrifice all we are as a nation for the security of mediocre 
medicine, bureaucratically administered.
  Ms. LINDA T. SANCHEZ of California. Mr. Speaker, whether all 
Americans should have access to quality health care at a reasonable 
price is a question a century old. First raised by Teddy Roosevelt in 
1912, then repeated by FDR, Harry Truman, and later presidents, the 
question almost answers itself. No nation can be strong whose citizens 
are sick and poor. To improve our economy, to care for our people, to 
fix our expensive and broken healthcare system, the time is now.
  Truman argued that the principal reason why people could not receive 
the care they needed in 1946 was that they could not afford to pay for 
it. At the time, the cost of health care accounted for 4 percent of the 
nation's income. Today, the reason people don't receive care most 
likely remains its unaffordability, but the aggregate cost of health 
care has since risen to 16 percent of the nation's income.
  Having grown up in a working family of seven kids, I know how 
important health insurance is. My parents couldn't predict which of us 
might break a leg, need our tonsils out, or worse, but they could 
predict that without insurance, they couldn't pay to get us the care we 
needed. There is no reason that hard working Americans should be priced 
out of needed healthcare.
  Without doubt, this is not a perfect bill. It does not contain strong 
employer responsibility provisions or a public plan to provide real 
competition to private insurers. It cuts DSH payments for hospitals too 
much. It benefits states that have left some of their poorest citizens 
out of Medicaid without rewarding states like California that have been 
doing the right thing all along.
  It contains an Independent Payment Advisory Board, which would 
severely limit Congressional oversight of the Medicare program and 
place authority within the executive branch, without Congressional 
oversight, judicial review, or state or community input. It also does 
something no bill has ever done before--prohibits undocumented 
immigrants from spending their own money to buy private health 
insurance within an insurance exchange or marketplace.
  But the bill's strength--that it makes health insurance accessible 
and affordable for more than 30 million Americans who currently lack 
insurance--is so much more important than its weaknesses.
  After fifteen months of hearings, meetings, debates, and ideas, the 
time has come for Congress to act to make healthcare better for all 
Americans.
  I take this vote after much thought and consideration, not for any 
politician, but for my constituents who are anxious about whether they 
will be able to afford care for themselves and their children when they 
need it. For a nation as wealthy as America to have tens of millions of 
people without health insurance is shameful.
  Even those who have insurance fear losing their jobs, and with it 
their insurance. Some are concerned that they will reach their annual 
or lifetime caps on coverage. Others are anxious that their insurance 
companies will simply drop them as soon as they get sick.
  This bill, which my constituents have told me this Nation desperately 
needs, will address a number of shortcomings in our current system.
  In our current system, those who have insurance pay more to subsidize 
care for those who don't have insurance. This bill changes that by 
requiring everyone to have basic health coverage. Everyone has a stake 
in improving public health. Currently, the uninsured don't get 
preventive care, and once they're sick, they wind up in the most 
expensive place to get treatment--the emergency room. The large number 
of uninsured distorts our system, acting as a hidden tax on the 
insured. This bill repeals that hidden tax.
  In our current system, those with pre-existing conditions are 
discriminated against. No child asks to be born with muscular 
dystrophy, juvenile diabetes, asthma, or Down Syndrome. Yet current law 
allows insurance companies to deny or limit their coverage. This bill 
fixes that injustice, protecting our children, and ensuring they can 
access coverage for life.
  In our current system, some women pay twice as much as men for 
insurance simply because they are women. This bill will change that so 
insurance companies will treat all people equally.
  In our current system, Americans who work just as long and just as 
hard as their fellow citizens often lack insurance simply because they 
work for a small company instead of a large one. This bill addresses 
that too, by creating generous tax credits to small businesses to make 
insurance more affordable, and by creating affordability credits to 
help self-employed folks buy insurance at an affordable price in an 
insurance marketplace.
  In our current system, healthcare costs are skyrocketing out of 
control. This bill will help rein in costs by paying doctors for 
quality, not quantity, and actually reduces the budget deficit, making 
our Nation more fiscally stable.
  Oh, and one more thing, in our current system, millions of Americans 
like their doctors and insurance companies. This bill allows you to 
keep them. Millions of Americans will see no change in this bill except 
for the added peace of mind that occurs when you are no longer at the 
mercy of an insurance company that can drop or deny coverage at the 
drop of a hat.
  And I haven't even mentioned the improvements to Medicare: closing 
the donut hole, eliminating co-payments on preventive tests, and 
reducing fraud and waste to extend the life of the Medicare Trust Fund.
  Yes, anyone who looks at this bill can find something wrong with it. 
But I can't remember the last time I voted on a perfect bill here in 
Congress. Just about every bill can be improved in one way or another.
  On balance, this bill does what I came to Washington to do: to give a 
voice to average working people, whose voices are too often drowned out 
by the voices of moneyed interests.
  Because I believe this bill would make America a stronger, more 
stable, healthier, fairer, and more just Nation, I vote yes.
  Mr. CONYERS. Mr. Speaker, I rise today in strong support of the 
American people's call to pass health reform, and I urge this body to 
pass this historic bill.
  We are here at this moment, principally, because of one number: 45 
million. These are the uninsured Americans, many of whom have lost 
their job and their health insurance in the worst economic downturn 
since the Great Depression. Today's vote on this imperfect legislation 
is necessary because our fellow citizens desperately need access to 
affordable comprehensive health care services. This legislation will 
give them that foot in the door and pave the way for greater future 
reforms.
  America remains the only nation in the industrialized world where 
health care is a for-profit corporate enterprise, where approximately 
45,000 uninsured people die each year from lack of coverage, and over 1 
million people go bankrupt each year.
  Let me be clear. This is not a perfect bill. I would have preferred a 
different approach that covered more people. But let me address those 
who oppose this bill. Tomorrow, they are going to wake up and our 
democracy will still stand. We will continue to live in the greatest 
country with the hardest working, most patriotic, freedom-loving 
citizens on the planet.
  The real impact of the bill will be felt tomorrow when:
  Insurance companies can no longer drop a person's coverage once they 
become sick;
  The average senior citizen will gain an additional $1,727 in 
prescription drug coverage; and
  Our children cannot be denied coverage based on pre-existing 
conditions and will be covered under our policies until they are 26.
  When health reform is fully enacted, approximately 31 million 
additional Americans will have access to health insurance, with 15 
million of them receiving care via an improved Medicaid.
  Don't let anyone fool you--Medicare will be strengthened by this 
bill. The only Medicare cuts in this bill are the billions in corporate 
welfare subsidies to health insurance companies that provide minimal 
benefit to seniors. The bill takes this wasteful spending and applies 
these funds to benefit consumers, not insurance companies. Medicare 
will become more affordable, offer more comprehensive benefits, and 
continue to provide peace of mind to America's seniors for years to 
come.
  We will not end our efforts to improve our health system with the 
passage of this bill. Just as we have improved Medicare and Social 
Security, so too will we strengthen this initial package of reforms.

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  Members of the Senate Leadership have made it clear they will revisit 
the idea of a public health insurance plan this year. I call on my 
fellow progressives to hold firm in our insistence on such a vote. The 
health insurance monopolies fear the competition an efficient not-for-
profit public health insurance plan would provide and that is exactly 
why we must have an up or down vote on this proposal.
  I support a public health option because I fundamentally believe in 
the value of public health insurance. For this reason, I remain an 
ardent supporter of universal single-payer health care. This system has 
successfully provided quality, affordable, and cost-effective health 
care wherever implemented, whether with Medicare, the U.S. military, 
Europe, Taiwan, or Japan.
  Adoption of a single-payer system is the only long-term means to 
eliminate the
corporate-medical-industrial-complex which threatens to undermine our 
health system with continued rising costs and an insatiable desire to 
pass costs onto already burdened citizens. For-profit investor-owned 
hospitals, prescription drug companies, and medical device 
manufacturers are just as culpable as the health insurance industry and 
future reforms must seek to address the profits-first mindset that 
prevails in these industries.
  If this bill passes, we should celebrate it. Tomorrow we will begin 
the work to make it better--to truly secure health care as a human 
right.
  Mr. KANJORSKI. Mr. Speaker, today I voted for legislation designed to 
improve the affordability and accessibility of health care. Americans 
already spend more on health care than the people of any other nation. 
If we take no action, health care costs are expected to double over the 
next 10 years, just as they have over the last 10 years. It is not the 
bill I would have written if it were up to me alone, but it is the best 
we can do at this time.
  This was one of the most difficult votes I have ever cast, primarily 
because there is a great deal of confusion about what this bill will 
do. Over the last year, many people throughout Northeastern 
Pennsylvania have taken the time to voice their thoughts on this health 
care reform bill, and I have taken each voice into consideration. I 
have heard the desperate pleas from people who have been sick and can 
no longer obtain any insurance. I have heard from small business owners 
who struggle to pay the premiums for their employees. I have also heard 
from a sizable number of my constituents who fear they will lose 
fundamental freedoms if this bill becomes law. From my careful review 
of the legislation, I have come to the conclusion that this fear is 
unfounded.
  Democracy requires the consent of the governed, but that consent 
needs to be informed with facts, not the widespread misinformation 
which has permeated the national conversation about this legislation. I 
had hoped that the House and Senate would conduct a conference 
committee to iron out the differences between the House and Senate 
bills televised by C-SPAN so that the American people would have an 
opportunity to understand the provisions included in this very complex 
bill. It is important to set the record straight between facts and 
myths.
  This bill does not empower the federal government to take over health 
care. In fact, this bill preserves the employment-based private 
insurance delivery system upon which a majority of working Americans 
relies for insurance coverage. It allows participants to choose the 
health insurance plan that best fits individual and family needs by 
creating a marketplace of insurance plans, resembling the Federal 
Employees Health Program used by all federal workers, including Members 
of Congress. The bill attempts to rein in those private insurers by 
prohibiting their most egregious abuses: denying coverage for 
individuals with pre-existing medical conditions, imposing a lifetime 
cap on medical care, and limiting the ability of individuals to change 
jobs without the fear of losing insurance coverage. It will also enable 
young adults to stay on their parents' insurance until age 26.
  If people currently have health insurance, whether it is through an 
employer or another means, their coverage will not change. If anything, 
their premiums are expected to decrease because there will be more 
people in the insurance pool. But, if people are unsatisfied with their 
insurance, they will have the capabilities to switch to a plan that 
best fits their needs.
  Senior citizens have expressed a great deal of worry that they will 
be denied services if this bill becomes law. In fact, seniors will 
experience better coverage for their prescription drug costs and will 
have no out of pocket costs for preventive care. In addition, this 
legislation reduces excessive payments to private insurance companies 
that administer Medicare Advantage Plans and applies those savings to 
the bill. It also works to reduce waste, fraud, and abuse in the 
Medicare program, which will help strengthen the program. As a result 
of this legislation, the non-partisan Congressional Budget Office (CBO) 
estimates that the solvency of the Medicare program will be extended by 
more than 9 years.
  This bill will help save American families money and prevent health 
care costs from bankrupting our country. The U.S. spent 16 percent of 
its gross domestic product, GDP, on health care in 2008, more than any 
other industrialized country. CBO estimates that number will rise to 25 
percent without changes to federal law. CBO also estimates that this 
bill will reduce the deficit by $138 billion over the 2010-2019 period.
  Many of my friends who oppose abortion have expressed concern that 
their tax dollars could be used to pay for abortions. I have been 
assured that this is not the case, and I am pleased that President 
Obama intends to issue an executive order to clarify that no funds in 
the bill will be used for abortion. Moreover, I will continue to remain 
vigilant to ensure that the Hyde Amendment, which prevents federal 
funding of abortion, remains the law of the land.
  I was greatly disturbed when the student loan legislation was hastily 
attached to the health care reform bill at the last minute because of 
the impact it would have on the 1,100 Sallie Mae workers in my 
district. Yesterday, Education Secretary Arne Duncan assured me that he 
will use all of the tools at his disposal to help ensure that these 
workers will remain employed.
  I thank the many Northeastern Pennsylvanians who have shared their 
thoughts with me on this important legislation over the past few 
months. When you are sick, the last thing you should have to worry 
about is how to pay the bills. Insurance is supposed to relieve this 
worry, but instead the current system has made that worry worse. Today, 
we are working to reverse this course.
  Mr. GALLEGLY. Mr. Speaker, if Congress wants to remove fraud and 
abuse from the healthcare system, it can start by overturning this 
bill.
  The Congressional Budget Office released an updated analysis of H.R. 
4872. According to the Congressional Budget Office, this bill will cost 
taxpayers $1 trillion. The analysis also confirmed that this bill will 
raise healthcare premiums $2,100 more a year for millions of families 
than if Speaker Pelosi had left healthcare alone.
  It also reaffirmed that as many as 9 million people now enrolled in 
employer-based plans will lose their coverage.
  At a time when our military men and women are fighting terrorists 
around the world, the national commander of the Veterans of Foreign 
Wars urged Congress to vote the bill down because it does not protect 
veteran healthcare plans.
  At a time when unemployment has hit a record 11.6 percent in Ventura 
County and 10.4 percent in Santa Barbara County, Speaker Pelosi's bill 
adds $569.2 billion of additional taxes onto the backs of American 
families and $52 billion on struggling employers.
  It hurts seniors with $200 billion in cuts to Medicare Advantage and 
raids Medicare and Social Security to fund the new mandate and hide the 
true cost of the bill.
  This bill must be overturned before the bulk of its provisions take 
effect in 2014. I support real reform that reduces premiums, reduces 
government spending and protects the doctor-patient relationship.
  I cosponsored a bill that would provide real reform, but Speaker 
Pelosi will not allow a vote on it. It includes:
  Allowing small businesses to band together to purchase health 
insurance for employees and use their combined bargaining power to 
negotiate better health benefits at lower prices.
  Reforming medical liability laws to discourage unnecessary and 
frivolous lawsuits, which only drive up prices for everyone and force 
doctors to practice defensive medicine.
  Removing unnecessary regulations that prevent health insurance 
companies from operating across state lines--which will provide the 
competition without government-run health care.
  Establishing high-risk pools to help people with pre-existing 
conditions find affordable insurance.
  I and many of my colleagues believe issues of portability, increasing 
costs and rescinding coverage must be addressed. However, in doing so, 
we must also protect a patient's right to choose the best coverage for 
him or herself in a vibrant, competitive marketplace, not force 
Americans into a one-size-fits-all government-run program designed by 
Speaker Pelosi.
  Mr. YOUNG of Florida. Mr. Speaker, four and a half months ago when 
the House first

[[Page 4180]]

considered health care reform legislation I voted against it saying 
that it did not represent good public policy.
  Nothing in the package of legislation we will consider today and 
tonight changes my mind. It is still not good public policy, it was not 
considered under an open process envisioned by the drafters of our 
Constitution, and it will drive up--not down--the cost of health 
insurance and medical care for individuals.
  This bill cuts Medicare by $523.5 billion. This cannot do anything 
but compromise the quality and availability of care for older Americans 
who depend upon the program for their medical care. The Chief Actuary 
for the Centers for Medicare and Medicaid Services confirmed that in 
December when he advised Congress that ``providers for whom Medicare 
constitutes a substantive portion of their business could find it 
difficult to remain profitable and, absent legislative intervention, 
might end their participation in the program (possibly jeopardizing 
access to care for beneficiaries).''
  A large percentage of my constituents in the 10th Congressional 
District rely on Medicare for their health care coverage and a large 
number of medical providers in my area care for a high percentage of 
Medicare patients. In a survey I sent to every registered voter last 
fall in my Congressional District, and to which more than 31,500 
responded, 83 percent of the respondents said they were opposed to 
paying for health care reform by cutting billions from the Medicare 
program. They are concerned about the cuts in this legislation for 
inpatient and outpatient hospital services, inpatient rehabilitation 
services, long term care facilities, skilled nursing programs, hospice 
services, kidney dialysis facilities, and medical laboratory services.
  If this is not of concern enough to our nation's seniors, the 
legislation we consider today cuts $200 billion from the Medicare 
Advantage program, through which an estimated 47,000 residents of the 
10th Congressional District receive their medical care. The Chief 
Actuary for Medicare has said that cuts of this magnitude would force 
more than 60 percent of these Medicare Advantage beneficiaries from the 
program. Nationally, that totals 4.8 million Americans who would lose 
their current coverage.
  Despite the fact that this legislation makes draconian cuts in 
Medicare, it will increase, not decrease, overall federal spending on 
health care. The non-partisan Congressional Budget Office (CBO) 
estimates that overall federal spending on health care will increase by 
$390 billion over 10 years. This is at a time when proponents of this 
legislation say it will save money.
  Supporters of this legislation also tout the expansion in health 
insurance coverage they claim it will bring about. However, this 
expansion is due in large part to increasing the Medicaid rolls. In 
fact, the CBO estimates that of the 32 million newly insured Americans 
under this legislation, half, or 16 million, will receive their 
insurance through the federally and state sponsored Medicaid program. 
At the same time, millions of people will be enrolled in subsidized 
plans on the government run health insurance exchanges and millions 
will lose their employer sponsored health insurance.
  Mr. Speaker, the majority of people I represent like the health care 
coverage they currently have and do not believe this legislation will 
improve the quality of their coverage. In my Town Hall by mail survey 
last fall, 73 percent of those who responded said they are satisfied 
with their current coverage and 70 percent say this legislation would 
not improve the quality of their coverage. Furthermore, 75 percent say 
Congress should not raise taxes to pay for this legislation and 74 
percent say individuals should not be required to purchase health 
insurance.
  Many constituents have also expressed their grave concerns about the 
insertion of the federal government into the precious patient-doctor 
relationship. A perfect example of this is the creation of 159 new 
boards, bureaucracies, and programs created in the 2,733 page health 
care bill.
  For example, in an effort to keep Medicare spending below targeted 
levels the legislation creates the Independent Medicare Advisory Board. 
This new entity will be required to submit recommendations to Congress 
to keep Medicare spending below targeted levels. This could result in 
additional coverage decisions being made by unelected bureaucrats 
largely or exclusively on cost grounds.
  Few issues have divided the American people as much as this health 
care debate and given the interest and passion they have shown on this 
matter demands that we give it serious consideration with a lot less 
politics. Many of us have suggested that we start with legislation in 
areas that we all agree we can fix now. That includes lowering health 
insurance costs by allowing small businesses and individuals to pool 
together in lower priced plans, requiring the coverage of individuals 
with serious pre-existing medical conditions, prohibiting insurance 
companies from canceling policies for those who become sick, 
prohibiting insurance companies from imposing arbitrary spending caps 
for policyholders, allowing families to purchase health insurance 
policies across state lines, closing the Medicare Part D doughnut hole, 
and providing for medical liability tort reform which the Congressional 
Budget Office says would save $54 billion over 10 years in large part 
due to lower medical malpractice premiums and the reduction of 
defensive medicine practices.
  In addition to Medicare cuts, the authors of this legislation pay for 
new big government programs by raising federal taxes by $569 billion 
over a ten year period. Many of those taxes will impact middle class 
families. These are families who will pay a penalty if they choose not 
to carry health insurance, the owners of small businesses who will pay 
a penalty if they do not provide health insurance for their employees, 
a sales tax on medical devices, a tax on prescription drugs, and a tax 
on health insurance premiums.
  This bill also violates the President's promise that if you like your 
insurance you can keep it. In addition to the 4.8 million seniors who 
will lose their coverage under the Medicare Advantage program, the CBO 
estimates that another 8 to 9 million people would lose their employer 
based coverage when their employers choose to drop their coverage or 
shift their coverage to the new subsidized policies on the health care 
exchange.
  This legislation would also contradict the President's promise that 
the cost of health care coverage would go down. Instead, the CBO 
estimates that the enactment of this legislation will raise private 
health insurance premiums from 10 to 13 percent.
  Mr. Speaker, most Presidents make it a practice of trying to bring 
the country together in the face of difficult issues. We did this in 
bipartisan fashion when it came to ensuring the financial solvency of 
the Social Security system, reforming our nation's welfare programs, 
and in engaging in an international war on terrorism. Yet this 
administration has sought to do it their way whether the country agreed 
or not.
  Tonight we are faced with legislation that affects every American, 
every American family, and every American business. The decision we 
make tonight could be irreversible and the changes to the Senate passed 
bill that are promised tonight may never take place. This is no way to 
conduct our nation's business. It engenders no level of confidence in 
the people who elected us to serve them.
  Mrs. CAPPS. Mr. Speaker, I rise in strong support of passing 
comprehensive health care reform legislation.
  This moment has been a long time coming. I've worked on health care 
since coming to Congress and passing comprehensive reform has always 
been a major goal of mine.
  I've met with and listened to my constituents, along with countless 
doctors, nurses, hospital administrators, researchers, and other health 
care experts. They know that America's health care system has many 
wonderful aspects: it can provide the most cutting edge care, cure 
diseases thought fatal only a few years ago, and devise new and 
exciting drugs, devices and treatments with mind numbing speed.
  But we also know our health care system's problems are legion. 
Coverage is erratic, incomplete and can evaporate without notice; costs 
are out of control for consumers, businesses and taxpayers; and health 
outcomes are actually better in dozens of countries that spend far less 
per capita than we do.
  The legislation before us addresses these problems and will help 
ensure that affordable, quality health care is always available to all 
Americans.
  The most trumpeted aspect of the bill is the coverage it would 
provide to some 32 million Americans who are currently uninsured, 
including an estimated 92,000 citizens in my own district. Passing this 
legislation is a matter of life or death for them as an estimated 
45,000 Americans die every year because they lack health care 
insurance. In addition, the uninsured are much more likely to forego 
primary care and delay other health care services leading to the 
development of otherwise preventable disease, requiring much more 
invasive and costly treatments.
  The bill expands Medicaid to provide coverage for more very low 
income individuals, and sets up state exchanges that will serve as 
marketplaces for individuals and small businesses to buy affordable 
health plans. The bill provides assistance to some individuals to 
purchase coverage and tax credits to small businesses so that they can 
provide health insurance to their employees. And it lets young adults 
stay on their parents' plans until age

[[Page 4181]]

26. These new mechanisms and support systems should provide coverage to 
the vast majority of today's uninsured, improving both the physical and 
financial health of millions of our fellow citizens.
  But, perhaps just as important, the bill offers critical protection 
for those already with health insurance. Today, insurance companies 
often drop consumers if they get sick, refuse coverage for so-called 
pre-existing conditions, and put annual and lifetime limits on a 
consumer's coverage. This bill puts an end to those unfair practices. A 
wife's diagnosis of cancer or a child's serious accident shouldn't be 
the cause for a family losing health insurance just when it is needed 
most.
  Those currently with coverage will also benefit through lowered 
insurance premiums. The Congressional Budget Office says premiums will 
be 14 to 20 percent lower per policy holder. Furthermore, the 
nonpartisan Robert Wood Johnson Foundation estimates that without 
health care reform individuals and families would see their health 
insurance premiums rise by as much as 79 percent over the next decade. 
That is unaffordable, unsustainable and just one of the many reasons we 
must enact this legislation.
  The bill also makes significant investments to train our next 
generation of doctors, nurses and allied-health professionals. This is 
critical because today's current shortages of nurses and doctors would 
only be exacerbated as we bring millions of new regular patients into 
the system without the appropriate investment in our health care 
workforce.
  The legislation will also make it much easier to access preventive 
health care services by eliminating co-pays for important recommended 
screenings such as those for heart disease or cervical cancer.
  Mr. Speaker, I've been hearing a lot from senior citizens concerned 
about what our health care reform proposal would mean for them.
  The bill will close Medicare's prescription drug ``donut hole,'' 
which in my Congressional district affects nearly 9,000 beneficiaries. 
It is unfair that policyholders should have to pay insurance premiums 
while receiving no coverage. The legislation before us today will give 
seniors who fall into the donut hole a $250 rebate this year, 50 
percent discounts on brand name drugs when they fall into the donut 
hole beginning next year, and completely close the donut hole by 2020. 
In addition to closing the donut hole, we take steps to crack down on 
fraud, waste and abuse which will extend the solvency of the Medicare 
Trust Fund by 9 years, according to CBO.
  Finally, this bill is the largest deficit reduction measure in a 
generation. According to CBO enactment of this legislation is projected 
to reduce the federal deficit by $130 billion by 2020 and by over $1.2 
trillion during the following decade. Earlier this year, the 
Democratic-led Congress reinstated tough ``pay-go'' budget rules the 
Republican-led Congress had allowed to lapse in 2003 and this health 
care bill is a reflection of our determination to bring our federal 
books back into balance as they were prior to the Bush Administration.
  Mr. Speaker, I will not argue this is a perfect bill because it is 
not. Most problematically, it lacks a public option, which would make 
the insurance market more competitive, ensure the greatest possible 
choice for consumers and bring down health care costs even more than 
the bill does already. I am also deeply disappointed the bill contains 
inappropriate language that may restrict a woman's access to 
reproductive health services.
  But I'm also not one to let the perfect be the enemy of the good and 
in this case, we have legislation that is very good and deserves our 
favorable consideration.
  I urge my colleagues to do the same.
  Mr. HOLT. Mr. Speaker, I rise today to support the health reform 
package we are debating today. It is an important, very beneficial step 
in America's history.
  I see the need for this legislation when I meet with my constituents, 
read their letters, and talk with them on the phone. A woman from 
Pennington, New Jersey called me yesterday. She was concerned that she 
would lose her job due to state budget cuts in New Jersey, which would 
mean that she would lose her health coverage as well. She told me her 
worries about finding affordable coverage while she looks for a new job 
and tries to keep food on her table. To complicate her situation, she 
has a pre-existing condition. This means that even if she could afford 
health care, it is possible she could be denied due to her pre-existing 
condition.
  This woman's story is not unique. At a roundtable in Trenton, a 
spouse of a cancer patient told me that when she and her husband came 
home from the hospital after one extensive treatment, they returned to 
foot-high stacks of insurance paperwork and $150,000 of out-of-pocket 
charges for her husband's needed care. A self-employed woman from East 
Brunswick wrote to me to let me know she pays $2,000 a month for her 
family's coverage and still sometimes has to pay out-of-pocket to see 
physicians.
  I vote for health reform to help middle-class women and men just like 
these hardworking New Jerseyans, who play by the rules and still find 
health coverage out of reach.
  Once reform goes into effect, families and small businesses will have 
more control over their own health care.
  Families with health insurance through their employers would benefit 
from caps on yearly out-of-pocket costs. Seniors would find that 
Medicare not only remains intact, but is improved--recipients would 
receive free preventive care and better primary care. Small businesses 
would have more health insurance options and additional support for 
their health insurance expenses. Patients with diseases such as 
diabetes or cancer would be able to obtain insurance without being 
turned away because of their pre-existing condition.
  The benefits of this health reform would be felt immediately upon 
enactment of the health insurance reform package. For example, small 
business owners who provide insurance for their employees would receive 
tax credits, families would no longer face annual or lifetime caps on 
their insurance benefits, and seniors with high prescription drug costs 
would receive $250 of additional assistance in their Medicare 
prescription drug plan.
  The health reform package would do all these things while reducing 
the deficit by $138 billion for the first ten years and by $1.2 
trillion in the next ten years.
  Today's vote is the culmination of over a century of debate about 
health reform. Since Teddy Roosevelt ran for President in 1912, our 
nation has been debating how to ensure that sick Americans can access 
the care they need. This Congress has been debating this health reform 
legislation in one of the most thorough processes in recent memory. 
During the past few years, the House of Representatives has held 79 
bipartisan hearings on health insurance reform, debated 239 amendments, 
and heard from 181 witnesses.
  The vote today brings this extensive process to a close at least here 
in the house, finally passing health reform legislation that will 
provide secure coverage to all Americans, ensure families have stable 
costs, and improve Medicare for our seniors.
  I urge my colleagues to vote in favor of this health reform package 
to provide health security to our nation's families and small 
businesses.
  Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of 
H.R. 4872, the Health Care and Education Affordability Reconciliation 
Act. I urge all my colleagues to support this bill because it will 
improve the accessibility and affordability of health care for millions 
of Americans.
  Today, there are more than 44 million Americans who lack health care 
insurance. We must ensure that the needs of these Americans are met. 
This bill will help us begin to do just that.
  While we in Congress have deliberated and debated the costs, 
challenges, and consequences of health care reform, millions of 
Americans continue to sacrifice, struggle, and suffer. Hundreds of 
people have sent me letters and e-mails, called and visited my office, 
and participated in town hall meetings to express their opinions. The 
majority of my constituents want and need health care reform. Many are 
unemployed and struggling to maintain their health care insurance while 
trying to make sure that there is food on the table, that they have 
shelter, and that their lights, gas, and water are on. Others are 
dealing with increases in health care premiums that continue to rise at 
the will of insurance companies. Still others are trying to get 
adequate treatment for serious illnesses and to pay for the medicines 
that can help them.
  I am a strong supporter of the single payer health care plan. I also 
support a strong public option. I support this bill because it begins 
the process of universal health care coverage for all Americans.
  This measure expands coverage to 32 million more people, or more than 
95% of Americans, while lowering health care costs over the long term. 
It prevents insurance companies from discriminating based on pre-
existing conditions, health status, and gender. It creates health 
insurance exchanges--competitive marketplaces where individuals and 
small businesses can buy affordable health care coverage--and offers 
premium tax credits and cost-sharing to low and middle income 
Americans, providing families and small businesses with the largest tax 
cut for health care in history. It also invests in Community Health 
Centers to expand access to health care in communities where it is 
needed most. The bill also empowers the Department of Health and

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Human Services (HHS) and state insurance commissioners to conduct 
annual reviews of new plans demanding unjustified, egregious premium 
increases.
  This bill puts patients and doctors in charge of their health care--
not health insurance companies. Children can no longer be discriminated 
against because of preexisting conditions. Seniors will no longer have 
to pay deductibles and co-pays. There will be free mandatory preventive 
health care provided for all under all health care plans. Plus, there 
will be a ban on lifetime coverage limits under this bill.
  The bill cuts taxes to small businesses to help small employers pay 
for health care coverage for their employees. Small businesses will 
have tax credits and vouchers so as to be able to afford health care 
coverage for their employees.
  The bill makes key investments in Medicaid and children's health. It 
expands eligibility for Medicaid to include all non-elderly Americans 
with income below 133% of the Federal Poverty Level and provides fair 
assistance to states to help cover the costs of these new Medicaid 
populations. The measure also maintains current funding levels for the 
Children's Health Insurance Program (CHIP) through fiscal year 2015 and 
increases payments to primary care doctors in Medicaid.
  The Health Care and Education Affordability Reconciliation Act 
strengthens Medicare. It adds at least nine years to the solvency of 
the Medicare Hospital Insurance Fund, fills the Medicare prescription 
drug donut hole, improves Medicare payments for primary care, and 
reduces overpayments to private Medicare Advantage plans. It also 
provides new, free annual wellness visits; eliminates out-of-pocket 
copayments for preventive benefits under Medicare, such as cancer and 
diabetes screenings; and provides better chronic care, with doctors 
collaborating to provide patient-centered care for the 80% of older 
Americans who have at least one chronic medical condition, such as high 
blood pressure or diabetes. The bill also encourages reimbursing health 
care providers on the basis of volume instead of value by including a 
number of proposals aimed at moving away from the ``a la carte'' 
Medicare fee-for-service system toward paying for quality and value, 
while reducing costs for America's seniors.
  This legislation reins in the abuse by health insurance companies of 
arbitrarily increasing premiums and stops insurance companies from 
dropping individuals from policies when people get sick and need health 
care insurance. If you change or lose your job, you will still have 
health care coverage. When you enter a hospital, you and your family 
can rest assured, knowing that your policy will cover the costs 
associated with your health care.
  Last, this legislation demonstrates fiscal sensibility and 
responsibility. It will reduce the deficit by $138 billion over the 
next decade, with an additional $1.2 trillion in additional deficit 
reduction in the following decade. The bill tightens current health tax 
incentives, collects industry fees, institutes modest excise taxes, and 
slightly increases the Medicare Hospital Insurance tax for individuals 
who earn more than $200,000 and couples who earn more than $250,000. It 
includes a fee on insurance companies that sell high cost health 
insurance plans to promote smarter, more cost-effective health coverage 
choices and changes health care tax incentives by increasing penalties 
on nonqualified distributions from health savings accounts, capping 
federal saving account contributions, and standardizing the definition 
of qualified medical expenses. The cost of health care reform under 
this legislation is fully paid for, in large part, by eliminating 
waste, fraud, abuse, and excessive profits for private insurers.
  As Democrats promised the American people, this bill is fully paid 
for. This legislation is the single largest deficit reduction tool in 
the history of our country. It is not balanced on the backs of our 
children and our grandchildren.
  My family and my faith provide the foundation for my commitment to 
service. I am honored and humbled to represent the people of the 13th 
Congressional District. As Members of Congress, we serve others. 
Through this service, we often provide people with the tools and 
resources they want and need. Our service not only changes us for the 
better by giving our lives meaning and fulfillment, but it also creates 
positive change in the lives of others. Like a raindrop in a river, our 
service creates ripples that leave an indelible impact on all those it 
touches.
  Today, we will make history by finishing what many Congresses before 
us started. The debate has gone on long enough. The American people 
want action. We must reject the status quo. We must stand up and do 
what is right. We must be a voice for the voiceless, give hope to the 
hopeless, and provide help to the helpless by supporting health care 
reform now.
  Let us be the light in the darkness by voting in support of the 
Health Care and Education Affordability Reconciliation Act. It will 
give much needed assistance to millions of Americans by making health 
care affordable for the middle class, providing security for our 
seniors, and guaranteeing access to health insurance for the uninsured. 
It is common sense for the common good, and I urge all my colleagues to 
vote yes on this historic measure.
  Mr. LARSON of Connecticut. Mr. Speaker, I rise on this momentous day 
in support of this historic legislation. Just as our predecessors stood 
up for the American people to pass Social Security and Medicare, today 
we affirm our commitment to families across this country by passing 
comprehensive health care reform. Today, Democrats are once again 
showing whose side they are on, the side of the American people.
  While my colleagues on the other side of the aisle like to focus on 
those who are against this effort, I've heard from too many of my own 
constituents whose stories exemplify why we need health reform and 
encouraged me to support this bill.
  Constituents like Jody from Bristol. Jody and her family had to 
downgrade their health insurance after their premiums jumped 30% in one 
year. Just a few months later Jody was diagnosed with Crohn's disease. 
After 12 months her medical debt was more than $30,000. Now, even after 
she has insurance, she is struggling to pay off the $35,000 in credit 
card bills her family amassed to pay her health care.
  It's in stories like these, of people facing severe financial 
difficulty because of medical debt, being denied coverage because of a 
pre-existing condition, or losing their coverage when they get sick 
that creates the moral imperative to right these wrongs. In this bill 
we will cap out of pocket costs, end discrimination based on pre-
existing health conditions, and end the practice of insurance 
rescissions.
  The American people may not like the complicated legal language of 
the bill or the messy process it takes in Washington to get historic 
acts accomplished. But after this bill is signed the parent whose 
children have been denied coverage because of a pre-existing condition 
will be able to get health insurance for them; young adults will no 
longer have to fear being without coverage because they will be able to 
stay on their parent's insurance; seniors will get relief from 
skyrocketing prescription drug prices; and small businesses will get 
tax breaks for offering their employees health.
  Once this bill is signed, this country will be stronger, the economy 
will be stronger and the American people will be stronger than ever 
before. I thank the Speaker and my Democratic colleagues for their 
efforts on behalf of the American people and urge my colleagues to 
support this legislation.
  Mr. GARAMENDI. Mr. Speaker, today, Democrats in the House of 
Representatives voted to form a more perfect union. By expanding health 
care coverage to 32 million Americans, we are continuing the proud 
American tradition of promoting justice, ensuring the general welfare, 
and broadening access to life, liberty, and the pursuit of happiness.
  Republican leaders in the 1930s said Social Security would lead to 
``the lash of the dictator'' and in the 1960s said Medicare would lead 
to grandparents telling stories of ``what it once was like in America 
when men were free.'' Yet with time, Social Security and Medicare 
became incredibly popular services cherished by most Americans. A 
broader consensus emerged, and a more perfect union was formed. I am 
confident that the same will soon be said about today's health care 
reform bill.
  When the people get past the slogans, the fear tactics, and the gross 
distortions, what they find in this legislation is a series of ideas 
widely popular and aligned with the best of American values. This is 
the second largest deficit reduction bill in 20 years. In my district, 
9,000 people with preexisting conditions will finally be able to have 
access to insurance. 96,000 seniors will see their Medicare improved 
with significant prescription drug discounts and free preventative 
screenings. 106,000 families will receive tax credits to make their 
coverage more affordable. 52,000 young adults will be able to attain 
coverage through their parents' insurance. 13,100 small business owners 
will receive significant tax rebates. 1,400 families will avoid 
bankruptcy. A similar story exists in every corner of this great 
country.
  In the fight to extend health coverage to every man, woman, and 
child, this bill is an incredibly important beginning. But it's still 
just a beginning. ``A more perfect union'' implies that the progress of 
the American experience is never complete. Each subsequent generation 
is expected to pick up the torch and continue

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on our long road toward positive change. Today the House of 
Representatives bestowed upon this great nation the most historic 
health reform since Medicare. I am proud to have voted ``yes'' for 
health care reform. I won't live to see a perfect union, but it is a 
tremendous honor to see a more perfect union formed before my eyes.
  Mr. OBERSTAR. Mr. Speaker, today the House of Representatives crosses 
a historic threshold in the evolution of social justice, quality of 
life, equity of health service delivery, and a worthy legacy for our 
children, with passage of comprehensive health care reform legislation.
  Our Nation enjoys the best, but the most expensive health care in the 
world. The comprehensive health care legislation under consideration 
will preserve what works best in our health care system and make that 
system more efficient and affordable.
  In Minnesota and throughout the Nation, citizens will quickly see the 
benefits of this legislation that includes important consumer 
protections to reduce the power of health insurance companies. You will 
have greater control of your health care decisions. This bill will 
assure that no one's current health care can be dropped. No one will be 
forced out of the health care they now hold. No one will be denied 
coverage because of a previously existing condition. No one's health 
insurance will be dropped because of lifetime caps; no one can be 
denied when they need their health insurance the most. People will be 
able to retain their health insurance if they change jobs.
  For seniors, the legislation closes the doughnut hole that has 
existed for five years, which will save seniors thousands of dollars in 
prescription drug costs. Young adults will be able to stay on their 
parents' policy until age 26.
  If we fail to provide health care for all of our citizens, we all 
will pay higher taxes and higher health insurance premiums because we 
eventually pay for ``sick care'' rather than make the wise investments 
in the promotion of preventive health care.
  This health care legislation, which assures that all Americans will 
be able to have and to keep health insurance, is central to our 
economic recovery and to balancing our federal budget.
  To be sure, this health care reform legislation will not cure every 
shortcoming in our health care system, but unquestionably the status 
quo is unacceptable and unaffordable. For far too long, too many 
citizens have been denied essential health care, and our commitment to 
fundamental justice demands that we make affordable access available to 
every American.
  This health care legislation will provide numerous benefits for 
Minnesota and the Nation. Importantly, this legislation expands access 
to health care to more than 32 million Americans. This expansion of 
health care will be achieved without increasing the federal deficit. 
The nonpartisan Congressional Budget Office has objectively analyzed 
the legislation and has determined that its enactment will reduce the 
deficit by $143 billion over the first decade and more than $1.2 
trillion over the second decade. The health care legislation is fully 
financed by ending the excessive subsides in the Medicare Advantage 
program and by additional changes in Medicare reimbursement that will 
make Medicare more efficient without reducing essential Medicare 
benefits; it will expand the solvency of the Medicare Trust Fund by an 
additional seven years.
  This health care legislation also includes important improvements in 
rural health care for Minnesota and the Nation. I was concerned that 
the original House health care bill did not incorporate a number of 
necessary reforms to expand access in rural America. I am pleased to 
report that the health care legislation under consideration not only 
expands health insurance coverage in rural America, but it also 
promotes the training and placement of health care professionals in 
rural areas. I am also very pleased that this legislation addresses the 
longstanding geographic disparity in Medicare reimbursement. Northland 
health care providers have been greatly disadvantaged by unfair 
Medicare reimbursement, and this legislation closes that gap and moves 
us inexorably toward payment parity with the rest of the country.
  Just as the Hippocratic oath requires that medical providers adhere 
to the admonition of ``First, do no harm,'' the same is true for 
legislators, and this legislation, while not perfect, will implement 
significant and positive changes in the delivery of health care.
  This is especially true with regard to vulnerable women and unborn 
children. I am confident that abortion will not be funded in this 
legislation. Current law dating back to October 12, 1979 (Public Law 
96-86), has contained a federal prohibition on the use of federal funds 
for abortion in community health centers. Conscience clause protections 
that have existed in the past, that are in effect today, will remain in 
effect in the future. The legislation also prohibits the use of federal 
tax credits and cost-sharing assistance to pay for abortion. I am very 
pleased that President Obama has prepared and will issue an Executive 
Order upon enactment to reaffirm the enforcement of current law that 
prevents the use of federal funds for abortion.
  Today, we keep faith with the American people. Today we ensure that 
quality, affordable health care is available to everyone to this 
generation and generations to come.
  Support this bill.
  Mr. TOWNS. Mr. Speaker, I would like to clarify several points in 
Section 1334 of H.R. 3590, regarding the Office of Personnel 
Management's authority to provide oversight and set premiums of multi-
State plans.
  OPM, of course, has administered the Federal Employees Health 
Benefits Program for over 50 years, and that program has served as a 
model for the Exchanges envisioned under this legislation. In 
administering the FEHB Program, OPM has been able to address the 
problem of uniformity of benefits and requirements across State lines 
using its authority under 8902(m) of Title 5. Section 1334(a)(4) of the 
Senate-passed bill states that ``the Director shall implement this 
subsection in a manner similar to the manner in which the Director 
implements the . . . Federal employees health benefit program under 
chapter 89 of title 5, United States Code''. The intent of this 
provision is that OPM oversee multi-State health plans in the same 
manner in which oversight is provided under the FEHB Program for the 
purposes of uniformity of health insurance plans. OPM should exercise 
this authority, as it does in the FEHBP, to ensure that multi-State 
plans offer uniform benefits, negotiate premiums with multi-State 
plans, and require these plans to set aside a certain amount of reserve 
funds. Moreover, it is imperative that OPM issue rules and guidelines 
as necessary to effectively and efficiently administer the multi-State 
plans, including for uniform adjudication procedures for disputes 
involving the multi-state plans.
  Another issue that requires clarification is the interaction between 
the Secretary of Health and Human Services and the Director of OPM. The 
legislation gives the Secretary broad authority to issue regulations 
governing the operation of State Exchanges. Any rule or regulation 
governing plans offered on State Exchanges would affect OPM's 
administration of the multi-State plans, which will also be offered on 
the Exchanges. There are overlapping responsibilities between HHS and 
OPM with regard to the multi-State plans offered on State Exchanges. 
The legislation envisions that the Secretary of HHS will coordinate and 
consult with the Director of OPM on any policy decisions that would 
affect the administration of multi-State plans. This joint effort is 
essential to ensuring the proper operation of the multi-State program 
as envisioned by Section 1334.
  Under section 1334, OPM is directed to ensure that sufficient 
resources are allocated to the ongoing administration of the FEHBP. The 
intent of this provision is to ensure that essential resources are not 
pulled away from FEHBP in order to start up the new program created by 
this bill. However, where greater efficiencies can be found from the 
administration of both programs jointly, we would expect OPM to adopt 
that approach.
  Lastly, section 2714 of H.R. 3590 would allow unmarried adult 
children to remain on their parent's plan up to the age of 26. Congress 
intends that this mandate apply to individual FEHB plans in their 
capacity as private health insurers and to the FEHBP as a group health 
plan. This Congressional Budget Office incorporated this interpretation 
of section 2714 in preparing its cost estimate of the legislation. 
Given the economic conditions in country, this is an important reform 
that will help families across the country, including the families of 
federal employees and retirees. I am pleased to support this provision 
as one of many reforms that will improve health care coverage for low 
and middle income Americans.
  Mr. BOUCHER. Mr. Speaker, health care reform is needed. More than 36 
million American citizens do not have health insurance, and millions 
more are underinsured and cannot afford to pay for the medical care 
they need. Those who have health insurance are finding that health care 
costs and health insurance premiums are rapidly rising. In fact, health 
insurance premiums are increasing 3.5 times faster than the rate of 
increase in family incomes.
  This status quo is unsustainable, and finding a way for everyone to 
afford health insurance is necessary to benefit both the uninsured and 
those who have insurance. It is also essential that health insurance 
reform control health

[[Page 4184]]

care costs and prevent rapid increases in health insurance premiums. 
But reform legislation must also ensure that the residents of my 
district in Southwest Virginia continue to have access to the high 
quality health care services that are now delivered locally.
  After reading and carefully reviewing the legislation, I oppose 
passage of the health care measure before the House today. My concern 
largely centers on the dramatic reductions in Medicare funding required 
by the legislation. Over the next 10 years, the bill requires that 
Medicare funding be reduced by $450 billion. In fact, in April of this 
year, doctors in our region and across the nation will have their 
Medicare payments reduced by 21 percent. Over the next several years, 
additional reductions in payments to doctors will occur. Other health 
care providers will also experience substantial reductions in their 
Medicare reimbursements. These Medicare payment reductions are fully 
accommodated by and expected to occur in order to achieve the $450 
billion Medicare payment reduction required by the reform legislation.
  The population of the Ninth Congressional District is more elderly 
than in the typical congressional district. Most senior citizens in our 
region depend upon Medicare to pay their medical bills. Therefore, 
these Medicare funding cuts will be far more harmful to the population 
of our region than to the population of the typical congressional 
district. The dramatic cuts in Medicare funding that would be required 
by the health reform bill would adversely affect the quality of health 
care for senior citizens and other Medicare recipients.
  Because Medicare is paying less, doctors, hospitals and other health 
care providers would increase charges to patients who have health 
insurance to make up for what they are not receiving from Medicare. 
This cost shifting of some substantial portion of the Medicare cuts 
would raise health insurance premiums for those who have insurance.
  While it is important that means be found to enable everyone, 
including those who are currently uninsured, to be able to afford 
health insurance, achieving that goal cannot occur at the expense of 
people who are currently insured. Having concluded that these dramatic 
Medicare cuts would both decrease the quality of health care that is 
delivered to our region's senior citizens and result in increases in 
health insurance premiums for the currently insured, I simply cannot 
lend my support to passage of the bill.
  I am also concerned about the unsavory deal-making that occurred in 
the United States Senate when the health care bill was considered in 
December. Some states received special benefits at the expense of other 
states. While the measure before the House today removes several of the 
special benefits, others remain and were not removed by the 
legislation. For example, the states of Louisiana, Tennessee, 
Connecticut and Montana have each received special benefits in the 
health care reform legislation not made available to other states. I 
simply cannot countenance this kind of deal-making which goes well 
beyond the bounds of normal legislative negotiations.
  In my view, the legislation does not do enough to eliminate the 
historical disparity in Medicare funding between urban areas and rural 
areas under which rural areas receive less than the urban regions of 
the country. There is no justification for Medicare paying less for 
medical procedures performed in our region than in the cities.
  The bill also fails to achieve the tort reform which is necessary to 
control health care costs. Virginia's tort reform law, which was 
adopted when I was a member of the Virginia General Assembly, has 
worked well, and I have urged that it be a model for national 
application. Unfortunately, the reform bill fails to include this 
needed provision.
  I deeply regret that the legislation does not have a bipartisan 
foundation. On a matter of this scope, affecting every American 
citizen, the best ideas of both political parties should be drawn upon 
in crafting balanced legislation that well serves the public interest. 
That did not happen as the reform bill was constructed.
  Reform is needed, but the measure being debated in the House today 
falls short. Because of massive funding reductions for Medicare, it 
would adversely affect the quality of care received by Southwest 
Virginia senior citizens. It would result in health insurance premium 
increases for those who have insurance. It contains unacceptable 
special benefits for some states at the expense of the others. It does 
not correct the unwarranted disparities in Medicare reimbursements that 
penalize rural areas. It does not contain meaningful tort reform, and 
it lacks the necessary bipartisan foundation.
  The reform legislation contains many helpful provisions; however, in 
my view its shortcomings outweigh its merits. I will cast my vote 
accordingly.
  Mr. PRICE of North Carolina. Mr. Speaker, ``once to every man and 
nation,'' wrote the great abolitionist poet James Russell Lowell, 
``comes the moment to decide.''
  Mr. Speaker, there are moments in history when it becomes clear that 
we simply cannot wait any longer to do what is right. When we have the 
opportunity to take a significant step to make our country better, the 
sort of opportunity that comes only a few times in a lifetime. We face 
such a moment tonight.
  Our health insurance system is falling far short of the American 
peoples' basic needs. It isn't working for families, who have seen 
their insurance premiums increase 75 percent over the past decade, 
while their earnings have risen only 14 percent. It isn't working for 
young adults, whose parents' policies stop covering them in their early 
twenties in most states, as if people that age don't need health 
insurance. It isn't working for people who have pre-existing conditions 
and can't find affordable coverage. It isn't working for the countless 
Americans whose coverage has been revoked when they get sick and need 
it most. And it isn't working for small business owners who want to 
provide coverage for their employees but can't access the low group 
rates that insurance companies willingly negotiate with large 
employers.
  Over the past year, I have attended numerous town hall meetings and 
roundtable discussions. I have met personally with doctors and 
patients, parents and children, seniors and students, business owners 
and employees. I have read thousands of letters and emails from 
constituents about this critical issue.
  In the course of these conversations, I have heard a rich and diverse 
range of views on the current state of our nation's health care system, 
but one conclusion has been shared by almost everyone: The status quo 
is unacceptable.
  Our current system penalizes the sick. It sells young people short. 
It puts small businesses--the primary engine of job creation in our 
country--at a competitive disadvantage. And instead of medicine, it 
offers seniors the Medicare doughnut hole.
  Why, then, would we continue to accept it? Particularly when we have 
before us a carefully crafted bill that directly addresses the system's 
flaws, preserves its strengths, and sets us on the path to meeting 
longer-term challenges.
  The time for reform is now.
  In an effort to defeat this bill, some of my colleagues have 
fabricated claims about ``death panels'' and damage to Medicare. They 
have raised the specter of ``socialism'' and ``government takeovers'' 
when they know quite well that this bill leaves the provision of care, 
and most insurance, in the private sector. They urge us to ``start 
over,'' but when challenged to come up with an alternative, they 
produced a plan that leaves insurance discrimination in place as well 
as tens of millions of uninsured.
  Reform will save money for employees, business owners, and taxpayers. 
It will end insurance company abuses. It will let young people stay on 
their parents' policies until age 27. It will extend coverage to 95 
percent of Americans. It expands community health centers and increases 
the number of primary care doctors and nurses. And it will end the 
hidden tax that the insured pay every month in the form of higher 
premiums.
  If my colleagues don't want to take my word for it, ask some of the 
people--right in their own backyards--who have lived through it 
firsthand. Ask David Swanson, whose insurance company raised the 
premium for his daughter's coverage 54 percent when she turned 17. Ask 
Blake Anderson, a small business owner who cannot afford coverage for 
his four employees. Ask Libbie Hough, who fears her 18-year-old 
daughter won't be able to find insurance when she finishes college 
because of a genetic disorder. Or ask the thousands of Americans who 
think they have good coverage until they get sick and hit annual or 
lifetime benefit caps, or lose their jobs.
  Mr. Speaker, the American people have waited long enough. We face an 
historic decision tonight, one that will resonate throughout our 
country, as have Social Security and Medicare, for decades to come. Let 
us seize the moment for the people we were elected to serve, and for 
future generations.
  Mr. RAHALL. Mr. Speaker, throughout my career of public service, 
there have been a few critical challenges that have remained at the top 
of my priority list; protecting our coal miners and our coal jobs and 
the need to provide our people with access to affordable, quality 
health care.
  Across southern West Virginia, especially in rural areas where senior 
populations are high, that challenge has been particularly daunting, 
because so many health insurance companies

[[Page 4185]]

have been increasingly putting high profit margins above all else, even 
the compassionate treatment of the sick and the elderly.
  I have consistently spoken out against the abuses of and mistreatment 
by huge, for-profit health insurance companies. And I have advocated 
for competition, recognizing that it is good for consumers and drives 
down prices for all buyers, while driving up quality of service.
  At the same time, I have consistently stood against the use of 
federal funds to pay for abortions--a stand I took again when I worked 
to have anti-abortion language included in the original House-passed 
health care bill. That was, in fact, one of many issues that I heard a 
lot about from West Virginians in recent months and that I successfully 
pressed to have addressed in the House bill.
  With the Executive Order strengthening the life protections in this 
bill, we have achieved a firm anchor for the protection of life in this 
country, reflecting the principles of the Hyde Amendment, no federal 
funding for abortions. Administrative chipping away and mischief will 
be held at bay with this order throughout this administration. Future 
administrations should be held to this standard.
  Health care is a deeply personal issue for all Americans. But it is 
also true that there are no people in the world more personally 
generous than Americans when it comes to helping the ill and the 
injured.
  I understand people's frustrations and concerns over coal, jobs, our 
economy. The rhetoric about health care this year has been emotional, 
at times angry, and, ultimately divisive. Much of the legitimate debate 
has been undermined by millions of dollars in advertising, underwritten 
by massive health insurance companies interested only in protecting 
their record profits and lucrative salaries. The result has been a 
polarized public and a polarized Congress.
  But underlying the most contentious, most calculatingly advertised 
issues, there can be found common ground. Certainly the status quo--
where honest, hardworking parents are forced into bankruptcy to afford 
lifesaving treatments for their child and where longtime, loyal workers 
lose their health care coverage along with their jobs during tough 
economic times--does not comport with American values.
  One of my constituents, Fred Long, is a Vietnam veteran and a proud 
West Virginian who has long had private health insurance. Fred, blessed 
with good health, needed his insurance little until he was 63 years old 
when he had to have cataracts removed from both eyes.
  Fred's brother was born with cerebral palsy. His problems were 
covered by SSI and Medicaid. He, too, had cataracts removed, but 
because of Medicaid, it did not cost his family a dime.
  The two brothers had the same procedure, used the same hospital, and 
same doctor, yet Fred's surgery cost him $3,099.36 despite Fred's $480 
a month health insurance premiums.
  Mr. Long closed his letter to me with this:
  ``. . . how many thousands of dollars have been paid in insurance 
premiums over the years . . . I don't know if this will be of any help 
in changing the thinking of those that can't see where national health 
care would benefit the working man.
  ``The insurance companies could have done this, collected from those 
that weren't sick and paid the heath care cost for those that were 
sick, just like the government helped my brother when he needed it. He 
is on Medicare now and I just hope I can get by the next few years when 
I can sign up for Medicare. (Sincerely, Fred Long)''
  Mr. Long's personal story echoes so many others I have heard from all 
across southern West Virginia--this is just one of the reasons I 
believe health care reform is necessary.
  We must end the polarization of America and find that common ground 
for the common good. The health care system as it currently exists is 
not sustainable for the long-term and this Nation has a host of serious 
challenges that cry out for attention--jobs for our people, renewed 
transportation funding for our highways, expansion of our technology, 
and diversification of our economy.
  Unfortunately, as long as the needs of the people can be subverted by 
special interests, financed by donors who operate in secrecy without 
any accountability to the American public, I worry that we will see 
little more than the same polarization that has dominated this Nation 
for months.
  Free speech is a wonderful American right that must be protected. But 
much of the speech we have been witnessing of late has been anything 
but free. It has been well-financed by special interests whose hands 
are in the pockets of political operatives, and their motivation is not 
the preservation of health care for our citizens, but, instead, the 
preservation of power for themselves. Worse still, to the degree that 
these operatives are able to bend government to suit their own 
purposes, you can be sure that others will line up to use the same 
tactics for their own good.
  This is bad for West Virginia. And it is bad for our Nation.
  Throughout my years of hard work for the people of West Virginia, I 
have worked with Republicans, Democrats, and Independents alike, always 
focused on the needs of southern West Virginia and the Nation. In all 
that time, I have used my experience, honesty, and integrity to sustain 
jobs for our coal miners, to ensure their health and safety and that of 
their homes and their families. I have fought to expand our job base 
and to build improved infrastructure, to advance technology, ensure 
veterans care, improve education, and protect our God-given natural 
resources, including the unborn.
  Today, I call for an end to the polarization. We must put away our 
personal interests, set aside our differences, and do the People's 
work. We must come together for the common good, using common sense.
  Ms. VELAZQUEZ. Mr. Speaker, for too long, working families have lived 
in fear that they are just one illness away from financial ruin. For 
too long, the men and women in my home state of New York have watched 
their premiums skyrocket, with family rates up 97 percent in the last 
decade. For too long, Latinos have been left behind, suffering the 
highest uninsured rate of any other community. Tonight, it is time to 
say enough.
  It is time to say enough to the discriminatory policies that charge 
women and minorities more money for the same services. It is time to 
say enough to a system that has pushed more than 2.5 million New 
Yorkers over the brink and into the ranks of the uninsured. And it is 
time to say enough to a status quo that robs Americans of the peace of 
mind that can only come from knowing this--they, and they alone, are in 
charge of their own well-being.
  Mr. Speaker, this bill gives every American that autonomy. For the 
Latino community, it delivers coverage to 8.8 million people. In my 
home district, it improves options for 324,000 residents, and expands 
care to 86,000 more. For 16,000 people with preexisting conditions, it 
allows them to buy affordable health plans right away, promising them: 
Never again. Never again can you be denied coverage. And for 4,300 of 
my district's seniors paying full price for prescription drugs, it 
closes the Medicare donut hole.
  Meanwhile, this bill invests in New York's network of community 
health centers. In my district alone, 33 clinics will see critical 
improvements, meaning more options for the men and women of Brooklyn, 
Queens and the Lower East Side. And at the end of the day, Mr. Speaker, 
isn't that what this legislation is all about--options?
  The Patient Protection and Affordable Care Act will deliver better 
choices--not just for New Yorkers, but for all Americans. With the 
passage of health care reform, we are finally answering a decades-long 
cry for help. We are finally empowering the American people with 
quality, affordable options that put them in the driver's seat, and I 
urge support of this landmark legislation.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise to claim time 
in support of the Reconciliation Bill and the Senate amendments to the 
Patient Protection and Affordable Care Act.
  Health care in the United States has degraded in accessibility and 
quality to the extent that we are a nation in crisis. Change is needed 
to truly make progress toward a healthier America, and the time for 
change is now.
  We are the closest in 60 years of legislative efforts to provide 
access to health care for all Americans. We must pass this legislation 
for the people.
  It is time to place compassion and dignity over corporate greed.
  My experiences as a legislator--and as a nurse--have provided a 
unique vantage point from which to discuss this issue. I have seen 
first-hand the state of affairs of our health care system.
  We cannot sustain the current system as premiums rise, prescription 
prices soar, and medical bankruptcies increase as services decline.
  Texas leads the Nation in uninsured, including the highest rate of 
uninsured children, and I am here today to stand up for my constituents 
who desperately seek access to care.
  Thousands of families are crushed by the growing cost of health care. 
This legislation reins in health care costs for families and businesses 
and reduces the deficit.
  We have come to a point where we must choose consumers over insurance 
companies.

[[Page 4186]]

Insurance companies have held the public hostage for many years, 
controlling and rationing care. It is time to give citizens the right 
to control their own health care.
  I stand in strong support of the legislation and urge my colleagues 
to do the same.
  Mr. COSTELLO. Mr. Speaker, we meet today for what will truly be a 
historic debate and vote on national health care reform. Like the 
passage of Social Security in 1935 and Medicare in 1965, it is sure to 
be one of a handful of votes that will stand the test of time as of 
great national significance. Also like those votes, the public debate 
surrounding national health care reform has engendered great passion on 
both sides, often generating more heat than light, but instructive all 
the same, as we must listen to all viewpoints as we contemplate major 
changes that will affect the entire country.
  Today's vote is a major milestone in what has been a decades-long 
effort to ensure access to quality health care for all Americans. In my 
district, 34,000 people are uninsured and use the hospital emergency 
room for treatment. Nine thousand people have a pre-existing condition 
that precludes them from getting insurance. Meanwhile, health insurance 
premiums have increased 131 percent over the last decade while wages 
have gone up only 38 percent. While the process over the last 14 months 
to develop health care reform legislation has been far from perfect, it 
is undeniable that our current health care system is broken, and we 
must take action to fix it. Toward this goal, I will vote in support of 
H.R. 3590 and H.R. 4872.
  This has been the hardest decision regarding a vote I have had to 
make during my service in the House of Representatives. During that 
time, I have strived to serve the people I represent with diligence and 
integrity, while remaining true to my core individual beliefs.
  One of those core beliefs is my support of protecting the unborn. I 
along with Congressman Bart Stupak (D-MI) and other pro-life Democrats 
have worked hard through the passage of the House bill and since the 
passage of the Senate bill to ensure that current law Hyde amendment 
abortion restrictions are applied to the final legislation. However, we 
were successful in convincing President Obama--a pro-choice President--
to issue an executive order that clearly states that the Hyde amendment 
will apply to the bill. This is a highly significant act. In addition, 
a colloquy on the House floor clearly stated that this is the intent of 
Congress. With these changes, I believe we have accomplished our goal. 
This belief is shared by the Catholic Health Association, NETWORK--a 
national Catholic social justice lobby, the Catholic Sisters--60 
Catholic women religious leaders representing 59,000 Catholic Nuns, and 
Democrats for Life.
  I stated that I would not vote for the Senate-passed bill in its 
current form. With the presidential executive order approving the Hyde 
abortion language and the fact that H.R. 4872 eliminates the 
``Cornhusker Kickback'' and other state-specific promises, combined 
with assurances from the Senate that H.R. 4872 will pass that body, I 
feel I can now support the Senate bill as amended.
  The fact is that this may be our last best chance to address a health 
care system that is unsustainable, that is spending $1 billion annually 
on medical costs for the uninsured while insurance premiums rise 
uncontrollably. Our current system is grossly inefficient and 
jeopardizes our future economic health. This legislation will insure 32 
million additional Americans, eliminate pre-existing condition 
restrictions, allow for the interstate sale of health insurance, 
eliminate lifetime caps on insurance benefits, allow dependent children 
to stay on their parents' insurance until age 26, and improve health 
care for seniors, all while reducing our budget deficit by $138 billion 
over the next 10 years, and by $1.2 trillion over the next 10.
  While the legislation will allow those that have health insurance to 
keep it, it will also end the fear that so many uninsured Americans 
have of becoming sick--of having to use their life savings or declare 
bankruptcy to pay for a medical emergency. It can be the difference 
that allows the disabled to live with dignity, and provides workers the 
confidence to reach their maximum professional potential.
  Mr. Speaker, after much deliberation, it is clear to me that we must 
take this opportunity to improve the provision of health care in our 
country. While it is a difficult thing to do, it is unquestionably the 
right thing to do, and I am confident that history will reflect this 
fact.
  Mr. SMITH of New Jersey. Mr. Speaker, for those of us who recognize 
abortion as lethal violence against children and the exploitation of 
women, nothing less than a comprehensive prohibition on public funding, 
promotion and facilitation of elective abortion in any federal health 
program, including the bill under consideration today, satisfies the 
demands of social justice.
  The Stupak-Pitts Amendment which passed 240-194-1 ensures that not 
some, but all the elements of the Hyde amendment applies to the 
programs that are both authorized and appropriated in this bill.
  By now, I trust that all members fully understand that because 
programs in Obamacare are both authorized and appropriated in this 
legislation, the actual Hyde Amendment has no legal affect. It only 
affects Labor HHS not this massive expansion of government funded 
health care.
  Regrettably the language that emerged from the Senate is weak, 
duplicitous and ineffective, not by accident, but by design. It will 
open up the floodgates of public funding for abortion in a myriad of 
programs resulting in more dead babies and wounded moms than would 
otherwise have been the case.
  Because abortion methods dismember, decapitate, crush, poison, starve 
to death and induce premature labor, pro-life Members of Congress, and 
according to every reputable poll, significant majorities of Americans 
want no complicity whatsoever in this evil. Obamacare forces us to be 
complicit.
  Abortion hurts women's health and puts future children subsequently 
born to women who aborted at significant risk. At least 102 studies 
show significant psychological harm, major depression and elevated 
suicide risk in women who abort.
  Recently, the Times of London reported that, ``[S]enior . . . 
psychiatrists say that new evidence has uncovered a clear link between 
abortion and mental illness in women with no previous history of 
psychological problems.'' They found, ``that women who have had 
abortions have twice the level of psychological problems and three 
times the level of depression as women who have given birth or who have 
never been pregnant . . .''
  In 2006, a comprehensive New Zealand study found that 78.6 percent of 
the 15-18 year olds who had abortions displayed symptoms of major 
depression as compared to 31 percent of their peers. The study also 
found that 27 percent of the 21-25 year old women who had abortions had 
suicidal idealizations compared to 8 percent of those who did not have 
an abortion.
  At least 28 studies--including three in 2009--show that abortion 
increases the risk of breast cancer by some 30-40 percent or more yet 
the abortion industry has largely succeeded in suppressing these facts. 
Abortion isn't safe for subsequent children born to women who have had 
an abortion. At least 113 studies show a significant association 
between abortion and subsequent premature births. For example a study 
by researchers Shah and Zoe showed a 36 percent increased risk for 
preterm birth after one abortion and a staggering 93 percent increased 
risk after two.
  Similarly, the risk of subsequent children being born with low birth 
weight increases by 35 percent after one and 72 percent after two or 
more abortions. Another study shows the risk increases 9 times after a 
woman has had three abortions.
  What does this mean for her children? Preterm birth is the leading 
cause of infant mortality in the industrialized world after congenital 
anomalies. Preterm infants have a greater risk of suffering from 
chronic lung disease, sensory deficits, cerebral palsy, cognitive 
impairments and behavior problems. Low birth weight is similarly 
associated with neonatal mortality and morbidity.
  Unlike both the Hyde Amendment and what would be the effect of the 
Stupak-Pitts amendment, the Senate passed bill permits health care 
plans and policies funded with tax credits to pay for abortion, so long 
as the issuer of the federally subsided plan collects a new, 
congressionally mandated fee from every enrollee in that plan to pay 
for other peoples abortions. Requiring the segregation of funds into 
allocation accounts--a mere bookkeeping exercise touted by some as an 
improvement to the new pro-abortion funding scheme--does absolutely 
nothing to protect any victims--baby or mother--from publically funded 
abortion.
  The Senate passed bill creates a new Community Health Center fund and 
appropriates at least $7 billion for Community Health Centers (CHC). 
Again recognizing that the Hyde Amendment does not apply to this bill 
and absent enactment of the Stupak-Pitts amendment, it is clear that 
the 1,250 CHC clinics (among the most effective means of reaching the 
poor and underserved with basic health care) will likely be compelled 
either by the Obama Administration or the courts or both to fund 
abortion on demand at CHC sites. There is no statutory protection 
against this abuse in the Senate-passed bill.
  Additionally, under the federal employee health benefits plan, which 
includes Members of Congress, since 1984, no funds may be

[[Page 4187]]

used for abortion or the administrative expenses in connection with any 
health plans that provide any benefit or coverage for abortions or even 
the administrative expense, except in the case of rape, incest or to 
protect the life of the mother.
  The Office of Personnel Management (OPM) administers the program.
  The Senate-passed bill on the other hand creates a huge new program 
administered by OPM that would manage two or more new multi-state or 
national health plans. The bill stipulates that at least one plan not 
pay for abortion. Which only begs to question: what about the other new 
multi-state plans administered by OPM? Why can those federally 
administered plans include funding abortion on demand? This represents 
a radical departure from current policy.
  Additionally, other appropriated funds in the bill have no Hyde/
Stupak-Pitts type protections either including $5 billion for a 
temporary high risk health insurance fund and $6 billion in grants and 
loans for health cover co-ops. Pro-life members who vote for this bill 
will roll the dice on this one.
  When the bill left the House, it contained the Hyde-Weldon language 
protecting health care providers who refuse to participate in abortion 
against discrimination by government entities. The Senate passed bill 
instead only includes more narrow text that prevents discrimination by 
a ``qualified health plan'' on the Exchange. This narrow language was 
included in the House bill, but without the additional protections 
against discrimination by federal and state governmental entities, pro-
life health care providers are not fully protected.
  Then there's the Mikulski Amendment, Sec. 2713, which empowers the 
HHS Secretary with broad new authority to compel private health care 
plans in America to cover ``preventable'' services. When Senator Ben 
Nelson suggested that abortion not be included in the so-called 
preventative services mandate, Ms. Mikulski said no--raising a serious 
red flag that abortion is being postured as ``preventable abortion 
service in the future''--after all, abortion prevents a live birth.
  Abortion as preventative health care isn't new.
  And as far back as 1976, Dr. Willard Cates, Jr. and Dr. David Grimes, 
then with CDC, presented a paper to a Planned Parenthood meeting, 
entitled: Abortion as a Treatment for Unintended Pregnancy: The Number 
Two Sexually Transmitted ``Disease''. To call pregnancy sexually 
transmitted disease; to call abortion a treatment or a means of 
prevention for this ``disease'' is barbaric.
  Abortion isn't health care--preventative or otherwise.
  Mr. Speaker, we live in an age of ultrasound imaging--the ultimate 
window to the womb and its occupant. We are in the midst of a fetal 
health care revolution, an explosion of benign innovative interventions 
designed to diagnose, treat and cure disease or illness any unborn 
child may be suffering.
  Unborn children are society's youngest and most vulnerable patients. 
Obamacare should do them no harm. Tragically, it does the worst harm of 
all. It kills them.
  Mr. FILNER. Mr. Speaker, I rise in support of this bill and I would 
like to take the opportunity to remind America's veterans that the plan 
will not affect the VA health care system. I continue to work in 
concert with leaders in the House of Representatives to ensure that 
veterans receive the world-class health care services they have so 
bravely earned.
  Let me be clear: enrolled veterans meet the individual responsibility 
requirements under the bill to maintain quality health coverage.
  I firmly believe all of our citizens should have access to health 
care. I am proud that Congress has crafted a plan to bring stability 
and security to Americans who have insurance today, and affordable 
coverage to those who do not. This plan, however, will not jeopardize 
the current health care services and benefits provided by VA. We will 
keep our promise to our Nation's heroes of the past, present, and 
future.
  I was pleased to sign a letter with House Armed Services Chairman Ike 
Shelton, House Ways & Means Chairman Sander Levin, House Education & 
Labor Chairman George Miller, and House Energy and Commerce Chairman 
Henry Waxman affirming that current health care reform legislation does 
not undermine or change the Department of Veterans Affairs mandate to 
provide comprehensive health care to veterans. I would like to submit 
this letter, along with statements from the Vietnam Veterans of America 
and AMVETS and a statement from General Eric Shinseki, Secretary of the 
VA, affirming this fact for the Record.

                                Congress of the United States,

                                   Washington, DC, March 21, 2010.
     Hon. Louise Slaughter,
     Committee on Rules, The Capitol,
     Washington, DC.
       Dear Chairwoman Slaughter: The House Democratic leadership 
     asked our committees to review HR 3590 and HR 4872 to assess 
     the impact of the bills on the health care provided by the 
     Department of Defense and the Department of Veterans Affairs. 
     Our reviews of HR 3590 and HR 4872 lead us to believe that 
     the intent of the bills was never to undermine or change the 
     Department of Defense and Department of Veterans Affairs 
     operation of their health care programs or interfere with the 
     care that our service members receive under TRICARE. However, 
     we commit to look into this issue further to ensure that no 
     unintended consequences may arise and to take any legislative 
     action that may be necessary.
       HR 3590, as drafted, does not specifically mention that 
     TRICARE coverage meets the individual responsibility 
     requirement. but such coverage would satisfy the requirements 
     of this bill. To affirm that this is the case, the U.S. House 
     of Representatives unanimously passed HR 4887, the TRICARE 
     Affirmation Act, which provides assurances to the American 
     people that care provided to those in the military and their 
     families, as well as military retirees under age 65 and their 
     families, would indeed meet the requirement for coverage.
       The members of our nation's military sacrifice much to 
     defend us all. We commit to these dedicated service members 
     and their families as well as our veterans that we will 
     protect the quality healthcare they receive,
           Sincerely,
     Bob Filner,
       Chairman, Committee on Veterans' Affairs.
     George Miller,
       Chairman, Committee on Education and Labor.
     Henry Waxman,
       Chairman, Committee on Energy and Commerce.
     Ike Skelton,
       Chairman, Committee on Armed Services.
     Sander Levin,
       Chairman, Committee on Ways and Means.
                                  ____

                                                   March 21, 2010.

 Vietnam Veterans of America Applauds Passage of Skelton Bill Ensuring 
  Protection of TRICARE, VA Health Care, and CHAMPUS; Decries ``Scare 
                               Tactics''

       Washington, DC.--`` We thank and applaud passage of H.R. 
     4887 yesterday in the House of Representatives, by a vote of 
     403-0. Passage of this bill ensures that health care programs 
     for veterans, active duty military, retired military, and 
     their families/survivors will not be affected negatively by 
     the pending health care reform legislation.'' said John 
     Rowan, National President of Vietnam Veterans of America 
     (VVA).
       ``It is unfortunate that some continue to raise what is now 
     is even more clearly a false alarm that is apparently meant 
     to frighten veterans and their families in order to prompt 
     them to oppose the pending legislation. While there is 
     legitimate debate as to whether or not the pending health 
     care measures should become law, VVA does not appreciate 
     spreading rumors that are not accurate by any political 
     partisan from any point of the political spectrum,'' 
     continued Rowan.
       ``Last summer there was a similar incident, also involving 
     partisans in the health care reform debate, that VVA soundly 
     condemned. We said then: ``It is our hope that sane minds 
     reject fear-mongering, and that veterans recognize these 
     scare tactics for what they are,'' Rowan said. Rowan 
     concluded by saying: ``VVA has always worked hard for justice 
     for veterans of all generations, and their families. We have 
     always, and will continue to, work with public officials 
     representing all political parties and points of view. Issues 
     affecting veterans and their families are not, should not, 
     and must not become partisan footballs to bat around. VVA 
     decries any effort, by anyone, that would do just that.''
                                  ____



                               Department of Veterans Affairs,

                                                   March 21, 2010.

              Statement from VA Secretary Eric K. Shinseki

       As Secretary of Veterans Affairs, I accepted the solemn 
     responsibility to uphold our sacred trust with our nation's 
     Veterans. Fears that Veterans health care and TRICARE will be 
     undermined by the health reform legislation are unfounded. I 
     am confident that the legislation being voted on today will 
     provide the protections afforded our nation's Veterans and 
     the health care they have earned through their service. The 
     President and I stand firm in our commitment to those who 
     serve and have served in our armed forces. We pledge to 
     continue to provide the men and women in uniform and our 
     Veterans the high quality health care they have earned.
       President Obama has strongly supported Veterans and their 
     needs, specifically health care needs, on every major issue 
     for these past 14 months--advance appropriations, new

[[Page 4188]]

     GI Bill implementation, new Agent Orange presumptions for 
     three additional diseases, new Gulf War Illness presumptions 
     for nine additional diseases, and a 16% budget increase in 
     2010 for the Department of Veterans Affairs, that is the 
     largest in over 30 years, and which has been followed by a 
     2011 VA budget request that increases that record budget by 
     an additional 7.6%.
       To give our Veterans further assurance that health reform 
     legislation will not affect their health care systems, the 
     Chairmen of five House committees, including Veterans Affairs 
     Chairman Bob Filner and Armed Services Chairman Ike Skelton, 
     have just issued a joint letter reaffirming that the health 
     reform legislation as written would protect those receiving 
     care through all TRICARE and Department of Veterans Affairs 
     programs.
                                  ____


      AMVETS Applauds Skelton Bill To Protect Military Health Care

       Lanham, Md. March 21, 2010--AMVETS leaders applauded the 
     passing of H.R. 4887, introduced by Rep. Ike Skelton, D-Mo., 
     that will protect specific health care benefits of military 
     veterans, members of the Armed Forces and their families.
       AMVETS National Legislative Director Raymond Kelly said 
     Sunday that AMVETS leaders have always understood the intent 
     of H.R. 3590: The Patient Protection and Affordable Care Act, 
     and believed it would not compromise the health care benefits 
     of American Veterans.
       ``AMVETS continues to share the opinion of Department of 
     Veterans Affairs Secretary Eric Shinseki and other VA and 
     Department of Defense leaders that health care reform 
     legislation does not threaten the veterans' community,'' said 
     Kelley. ``The successful passing of Rep. Skelton's 
     legislation only solidifies our belief and erases any and all 
     doubt of potential harm.''
       Kelly said AMVETS will continue to monitor the debate to 
     ensure the Senate version of H.R. 4887 also passes.

  Ms. HIRONO. Mr. Speaker, today we take a stand for hard-working 
middle class families who deserve a better value for their health care 
dollar. We take a stand for better health care for America's seniors. 
We take a stand for those who have been denied insurance coverage 
because of a preexisting condition or whose insurance is rescinded when 
they need it most.
  This has been a difficult debate. There are strong, personal feelings 
about the issue of health care, because it affects all of us. This 
makes it even more important that we focus on the substance of health 
care reform, rather than engage in demagoguery, name calling, and 
worse. Republicans and Democrats alike know that our health care system 
is broken and not sustainable. Our country spends more on health care 
than any other developed country and we fall far below these other 
countries in the health of our people.
  H.R. 4872 and the Senate health care reform bill, H.R. 3590, are not 
perfect, but they are a step in the right direction. The health 
insurance reform measure achieves the three key goals of affordability 
for the middle class, accessibility for all Americans, and 
accountability for the insurance industry.
  More than 350 organizations support the health insurance reform 
legislation that we are voting on today. They include: the American 
Medical Association, AARP, Catholic Health Association, Main Street 
Alliance, Federation of American Hospitals, National Association of 
Public Hospitals and Health Systems, American College of Physicians, 
Paralyzed Veterans of America, American Heart Association, American 
Cancer Society Cancer Action Network, American Diabetes Association, 
American Nurses Association, Families USA, National Committee to 
Preserve Social Security and Medicare, National Women's Law Center, 
Consumer Federation of America, and the Consumers Union.
  Once this bill is passed, Americans will see immediate benefits: 
seniors will start to see immediate relief from high prescription 
prices with a $250 rebate for Medicare beneficiaries who hit the donut 
hole; preventative services and immunizations will be free under 
Medicare right away--eliminating co-payments for preventative services 
and exempting preventative services from deductibles; and small 
businesses that provide coverage to their employees will be eligible 
for a tax credit of up to 35% of premiums. The bill will also ban 
insurers from denying coverage to children with pre-existing conditions 
and eliminates lifetime limits and restrictive annual limits on 
coverage.
  These are real reforms yielding real benefits to people who are not 
getting their money's worth from the current system. It will soon be 
much harder to mischaracterize what this effort to change the health 
care system has been about once reform is enacted and the benefits 
accrue.
  I was appalled at the news that my colleagues John Lewis, Andre 
Carson, Emanuel Cleaver, and Barney Frank were verbally insulted and in 
one instance spat on by anti-health care reform protestors yesterday.
  The ugliness that this behavior exemplified reminded me of why ``Live 
Aloha'' is more than a motto to us in Hawaii. The Hawaiian word aloha, 
has deep meaning in my state; it is far more than hello or goodbye. To 
``Live Aloha'' is to also have respect for yourself and respect for 
others, especially those with whom we disagree. To treat each other 
with decency--not hatred, or racism, or bigotry--is to ``Live Aloha.'' 
I'm proud to represent a state where we strive toward that ideal.
  My office has taken many calls and received many emails and letters 
on health care reform. A call that my office received on Friday was 
particularly heartfelt. It was from a woman on the island of Kauai who 
called to tell me that she and her 93 year-old friend both wanted me to 
stay strong and to vote in support of health care reform. I mention 
this particular call because it reminded me of the people and places I 
represent, who I fight for every day, and what this health care debate 
is all about.
  In his recent address to the Democratic Caucus, President Barack 
Obama quoted President Abraham Lincoln who said, ``I am not bound to 
win, but I'm bound to be true. I'm not bound to succeed, but I'm bound 
to live up to what light I have.'' This bill calls us to be true to the 
millions of Americans who want and need enlightened health care reform. 
It is a privilege to vote for H.R. 4872.
  Mr. STARK. Mr. Speaker, This is a historic day. We have worked to 
enact health reform in America for decades. President Johnson took a 
major step when he signed Medicare into law in 1965 and guaranteed 
every American age sixty-five and over quality, affordable health care. 
Forty-five years later, we are about to extend that guarantee to all 
Americans.
  It isn't the bill I would have written. However when it comes to 
legislating health insurance reform in America, we will not get 
everything each of us want. This bill is a compromise that bridges the 
differences among us.
  I am proud to support this legislation and urge my colleagues to do 
the same.
  This bill builds a solid foundation. It will:
  Extend coverage to 95 percent of all Americans.
  Assure affordability of health insurance by providing tax credits and 
cost-sharing assistance to families up to 400 percent of poverty.
  Halt abuses of the health insurance industry--forcing them to compete 
on quality, not just their ability to avoid covering needed health 
services.
  Guarantee a standard benefit package for all Americans with an annual 
cap on out-of-pocket spending. No family should go bankrupt because of 
medical expenses.
  Create a new marketplace, called an Exchange, where people will be 
able to comparison shop among health insurance plans.
  Require that insurance plans spend at least a certain percentage of 
their premium dollars on benefits and end discrimination by health 
status, gender, occupation.
  Help senior citizens by filling the Republican Medicare prescription 
drug donut hole--ensuring that Medicare beneficiaries will be able to 
afford their medications year-round.
  We are joined in support of this legislation by a coalition of 
patients, doctors, nurses, hospitals, businesses, labor unions, 
children's advocates and senior citizens.
  President Obama has worked tirelessly to achieve this goal and he 
deserves much of the credit.
  There are components I wish had turned out differently and I pledge 
to continue working to improve them. In particular, I have some 
concerns about Medicare.
  I oppose the inclusion the Independent Payment Advisory Commission, 
called IPAB. Some of my colleagues support this Commission because it 
shields them from having to take tough votes when it comes to cutting 
Medicare provider payments. It's my experience that Congress always 
does what is needed to protect and strengthen the Medicare program. 
IPAB is a dangerous provision. By statute, this Commission would be 
required to hold Medicare spending to an arbitrary and unrealistic 
growth rate. It is a mindless-rate cutting machine that sets the 
program up for unsustainable cuts. That will endanger the health of 
America's seniors and people with disabilities. It is an unprecedented 
abrogation of Congressional authority to an unelected, unaccountable 
body of so-called experts. I intend to work tirelessly to mitigate the 
damage that will be caused by IPAB.
  I am pleased that this legislation reduces government overpayments to 
private health insurance plans in Medicare and that our reconciliation 
negotiations improved on those savings. It still should eliminate the 
overpayments. I support the choice of private plans in Medicare, but I 
don't support wasting taxpayer dollars on corporate subsidies to 
achieve that

[[Page 4189]]

goal. Plans that can meet or beat Medicare should be allowed to 
participate. Those that can't should be excluded. We've got more work 
to be done here.
  We also lost a provision in the House bill that ensured Medicare 
beneficiaries in private plans would never pay higher cost-sharing for 
Medicare services than if they were enrolled in traditional Medicare. 
I'll be working with the Administration to see that they move forward 
with steps in their authority to resolve that disparity.
  I am disappointed in the lack of a public health insurance option. 
This provision fell victim to the strength of the insurance industry 
lobby. It would have saved taxpayers money, enhanced competition, and 
increased efficiencies. That it isn't in this bill does not mean it 
can't be added in the future.
  These flaws are what one must expect when bringing a bill through the 
US Congress that touches more than one-sixth of our economy. In the 
past, we've allowed health reform to fail because of similar 
imperfections. We, can't let that happen now.
  Our vote today will determine whether we finally provide affordable, 
quality health care to all Americans. I am proud to rise in support of 
this legislation, and I urge my colleagues to join me in voting yes.
  Mr. PIERLUISI. Mr. Speaker, I rise so that the record will reflect 
the following point about the Medicare Advantage program and its 
application in Puerto Rico. For a variety of reasons, relatively few 
Medicare beneficiaries in Puerto Rico are enrolled in Part B. The 
Medicare Payment Advisory Commission (MedPac) has determined that, as a 
result, fee-for-service reimbursement rates for providers on the Island 
are artifically low and unstable. Over the past year, I have worked 
with the House Committee on Ways and Means to examine ways to address 
this problem. In the report accompanying the health care reform bill it 
approved, the Committee candidly acknowledged the problem and urged CMS 
to use its existing authority to adjust the reimbursement rates in 
Puerto Rico. I strongly supported this language and believe it is still 
operative. Working with Committee leadership and my colleagues, I will 
do everything within my power to ensure that CMS uses its current 
authority to make certain that reimbursement rates to MA providers in 
Puerto Rico are fair.
  The language included in the House Ways and Means Committee report 
is:
  The phase-down of MA payments to FFS costs applies equally to all 50 
states and the territories, however, Puerto Rico is a unique situation 
that the Committee expects that the Secretary will use authority under 
current law to examine. Specifically, very few Medicare beneficiaries 
in Puerto Rico choose to enroll in Part B; instead, MA plans buy down 
the Part B premium for enrollees and therefore many Medicare 
beneficiaries enroll in MA to receive all of their Medicare services.
  With only a small population enrolled in Part B through traditional 
Medicare, the county FFS expenditures calculated by the Secretary are 
artificially low and unstable from year-to-year. Therefore, the 
Committee expects that when calculating county FFS rates in Puerto 
Rico, the Secretary will use utilization and expenditure data from MA 
plans under current authority and adjust these rates and risk scores 
appropriately.
  Mr. SMITH of Texas. Mr. Speaker, by a 12-point margin, Americans say 
the Administration's health care plan is a ``bad idea,'' according to a 
new NBC News/Wall Street Journal survey.
  And the number of people who call the health plan a ``bad idea'' has 
reached a new high.
  But you won't hear about this from the national media--not even NBC, 
who conducted the poll. During a report about the survey on NBC's 
Nightly News, anchor Brian Williams failed to mention this finding.
  Other polls show even greater opposition to the Administration's 
plan. According to Investor's Business Daily, Americans want Congress 
to ``start fresh'' by 61 percent to 32 percent.
  NBC and the national media should give the American people the facts 
about health care, not hide them.
  Mr. HASTINGS of Florida. Mr. Speaker, we are on the brink of passing 
a bill that will lay the foundation for comprehensive health care 
reform. We have discussed and debated various aspects of this bill for 
over a year. Now, it is time to act.
  Developing and executing major reform efforts has never been easy or 
pretty. Violent and divisive debates waged when Congress was 
considering legislation that instituted Medicare.
  And yet, few would dispute that this program is essential to 
delivering quality health care to some of our Nation's most vulnerable 
communities--the elderly and disabled.
  Like reform efforts of the past, the health care reform bill has been 
met with blind criticisms and incessant fear mongering. Amazingly, some 
of my colleagues talk about horrific scenarios that will result from 
passing the bill and ignore the horrific conditions that people are 
enduring right now. They don't speak for me. They don't speak for the 
161,000 uninsured Floridians in my district, and they don't speak for 
people who know that this bill is fiscally responsible and takes a 
multifaceted approach to improving our health care system.
  Every single day, people are forced to choose between paying their 
mortgage or financing costly life-saving treatments. Every single day, 
seniors are forced to choose between buying food or buying their 
medication. Every single day, people are dying prematurely because they 
don't have regular access to health care services. You can't tell me 
that these people don't want or need health care reform.
  Mr. Speaker, health care reform boils down to whether you believe 
that 47 million uninsured Americans is an unfortunate but acceptable 
fact, or an injustice that must be addressed.
  Achieving comprehensive health care reform requires a uniquely 
American approach that preserves what works and introduces new elements 
that will allow us to meet 21st century needs and goals. This reform 
bill does just that. I urge my colleagues to vote in support of this 
historic bill and ensure that our fellow Americans have access to 
affordable and high quality health care.
  Ms. BERKLEY. Mr. Speaker, I rise today in support of health care 
reform.
  While not perfect, this bill addresses key obstacles that continue to 
plague the system. The cost of health care premiums is skyrocketing out 
of control, creating an atmosphere where only insurance companies can 
and will prosper and prevail. Without this reform, our individual 
citizens and businesses will continue to be devastated by unsustainable 
costs or barriers to coverage.
  This bill would increase access for those who have been denied 
insurance in the past, either because they can't afford it, have a pre-
existing condition, or have been dropped from coverage after getting 
sick. It would provide financial assistance to working families to make 
their health care costs affordable and it would provide businesses with 
tax credits for providing health care for their employees.
  In my district, this bill would extend coverage to 155,500 uninsured 
residents, guarantee that 26,200 residents with pre-existing conditions 
can obtain coverage, reduce the cost of uncompensated care for 
hospitals and other health care providers by $74 million annually, and 
allow 63,000 young adults to obtain coverage on their parents' 
insurance plans.
  I believe it is my duty to fight for the health, well-being and 
protection of the citizens I represent. While this package does not 
contain all the reforms needed, it provides a framework of very 
positive first steps that will achieve a great deal for Nevada 
families. There is no doubt that more must be done, but I believe this 
is a step in the right direction. I urge my colleagues to vote yes on 
this legislation.
  Mr. PLATTS. Mr. Speaker, all members of Congress agree that the 
status quo in health care is unacceptable and that we must act to make 
affordable, quality health care accessible for all Americans. The 
legislation before us today, however, is the wrong solution. Simply 
put, it is bad public policy.
  Throughout the debate on health care reform, I have emphasized that 
Congress must be certain to adhere to the physician's principle of 
``First, do no harm.'' Unfortunately, the Senate-passed health care 
bill (H.R. 3590) and reconciliation legislation (H.R. 4278) that we are 
considering today will do significant harm.
  A primary focus of health care reform must be on bringing down the 
rapidly rising cost of health care and health insurance. Instead, the 
legislation before us today costs over $1 trillion in the first 10 
years. When fully implemented, the proposed plan's costs will total 
more than $200 billion per year. That's $2 trillion in additional 
health care-related costs over the course of the plan's first full 
decade of implementation. Once the budgetary gimmicks are stripped 
away, the legislation before us will increase the overall budget 
deficit dramatically.
  According to the Congressional Budget Office (CBO), the proposed 
legislation will do significant additional harm as well. CBO analysis 
concludes that health insurance premiums in the individual market will 
increase by 10-13%, Medicare will be cut by more than $500 billion, 
taxes will increase by $579 billion, and millions of Americans will 
ultimately be forced off private health insurance plans into 
government-run plans.
  Countless new taxes are included in the proposed health care 
legislation. For example,

[[Page 4190]]

new taxes would be imposed on: individuals without health insurance; 
employers, whether they provide health insurance for their employees or 
not; certain employer-provided health insurance plans, more and more of 
them over time; medical devices, like wheelchairs and walkers; 
investment income; Flexible Spending Accounts; and health insurers and 
pharmaceutical companies, taxes that are likely to be passed along to 
their customers.
  The proposed legislation's cuts to Medicare will detrimentally impact 
millions of senior citizens. For example, CBO estimates that, as 
drafted, the cuts to Medicare Advantage funding will result in 
approximately 4.8 million seniors losing access to such plans. Plans in 
which they chose to enroll.
  Mr. Speaker, the process by which we are considering these bills is 
also wrong. Ordinarily, the reconciliation process is used to pass 
legislation making changes in existing federal programs or taxes. The 
reconciliation legislation under consideration today will make changes 
to a health care bill that has yet to even be enacted. Importantly, 
there is no guarantee that the reconciliation bill will be passed in 
the Senate. This means that the House would be effectively trusting 
that the Senate health care bill will be ``fixed'' by the 
reconciliation process, even as the Senate health care bill is approved 
by the House and becomes law.
  The entire health care reform legislative process has been tainted by 
proposals offered along the way to gain votes--like the infamous 
``Cornhusker Kickback,'' as well as special provisions for other states 
that have undermined confidence in the final product. Similarly, the 
House leadership's initial plan of using a ``deem-and-pass'' 
legislative tactic--enacting the Senate bill into law without a 
straight up-or-down vote--greatly diminished the American people's 
trust in this legislation's provisions.
  Rather than enacting the legislation before us today, Congress should 
restart the process and enact common sense health care reforms that 
have bipartisan support. Reforms such as small business health 
insurance pools, medical malpractice liability reform, tax credits and 
deductions for health care expenses, and insurance reforms addressing 
the issues of pre-existing conditions and wrongful coverage termination 
will better ensure access to affordable, quality health care for all 
Americans, while also adhering to the physician's principle of ``First, 
do no harm.''
  Mr. COOPER. Mr. Speaker. I woke up this Sunday morning, said my 
prayers, and finally decided that I will vote ``yes'' on health care 
reform.
  Having heard from tens of thousands of Middle Tennesseans on all 
sides of the issue (including the flood of messages in the last few 
days and hours), and having spent months studying the various bills, I 
know that America must improve its health care system because it is 
unsustainable. This legislation will make it better.
  Any decision of this magnitude must be made very carefully, after 
weighing every concern. We Nashvillians are proud of our outstanding 
health care community that makes us ``the nation's health care industry 
capital.'' Given our community's expertise, it is interesting to note 
that:
  Every Nashville hospital strongly supports the legislation, whether 
it's St. Thomas, Vanderbilt (both University and Hospital), Centennial, 
Meharry Medical School, Nashville General, Summit, Skyline, or Southern 
Hills.
  A majority of physicians who contacted me support the legislation 
and, although the Tennessee Medical Association opposes it, the TMA's 
national organization, the conservative American Medical Association, 
supports it.
  A majority of local nurses support the legislation, along with the 
American Nurses Association.
  Despite media controversy regarding abortion, the Catholic Health 
Association, Catholics United, and groups representing 59,000 Catholic 
Sisters support the legislation.
  The largest Nashville and national senior organization, AARP, 
supports the legislation.
  It means a lot to me that so many local people who know so much about 
health care agree with my decision.
  Of course, there are plenty of people who disagree who are also very 
knowledgeable about health care, and I have great respect for their 
opinions. I've learned a lot from their views. Several of their 
suggested improvements are already in the legislation. You may be 
surprised that many of these critics want the legislation to do more, 
not less. Having taught health policy at Vanderbilt's business school 
for many years, I can easily point out many flaws in the legislation 
myself, both substantive and procedural. I have been working hard in 
Congress to eliminate those flaws. For example, yesterday we were able 
to force a clear, up-or-down vote on today's legislation instead of 
using the parliamentary maneuver that was favored by some in my own 
party.
  Let me make clear that I respect the advocacy of those who are 
opposed to the legislation. They actually help me make sure that more 
people in Congress do their homework and pay attention to America's 
financial problems. They are strengthening our democracy with their 
voices.
  The bottom line is that this legislation offers the only realistic 
hope that most Americans have for getting a fair deal in today's 
private health insurance markets. This is not a government takeover of 
those markets, but a way to encourage better private-market 
competition. In the future, private insurance companies should compete 
to keep us healthy, not drop us from coverage. Tens of millions of 
Americans will benefit immediately from reform of these insurance 
markets. Thousands of lives will literally be saved due to the greater 
affordability of health insurance. This is as major a public health 
accomplishment as reducing car wrecks or finding a cure for a dread 
disease. One of the lives saved could be yours.
  My health insurance is Tennessee Blue Cross/Blue Shield (just like I 
had when I was a small businessman in Nashville) but, as a Congressman, 
I am able to purchase it as part of a large pool, an exchange. I want 
every American to have the same purchasing power. No matter what your 
insurance company is, most Tennesseans are only one illness away, one 
pink slip away, or one premium hike away from being mistreated by 
current insurance practices: discrimination against pre-existing 
conditions, arbitrary premium pricing, and last-minute rescission of 
coverage when you need it most. This legislation will cover 32 million 
hardworking, middle-class Americans who are left out in the cold by 
today's insurance practices. Rival legislation only attempts to cover 3 
million uninsured people, or less than 10% of the problem. America can, 
and must, do better.
  The financial issues involved are just as important as the coverage 
issues, as I pointed out in my remarks at the President's bipartisan 
summit on health care at Blair House in February. Will improved 
coverage increase the deficit, either short-term or long-term? And will 
this legislation start containing the explosion in health costs that 
threaten our economy but do not improve our health?
  Although CBO claims that the legislation will reduce deficits in the 
first ten years by over $100 billion, and by over $1 trillion after 
that, you don't have to believe CBO to realize that, even if you assume 
zero deficit reduction, this is a huge improvement in the policymaking 
of recent years. In plain English, this bill is paid for, and may even 
save big money. Should these projections prove faulty, there are fail-
safe mechanisms within the legislation that, with public support, 
should correct any budget problems. I proudly voted against the 2003 
Medicare drug bill because it did not even attempt to pay for itself. 
That one bill (which very few constituents complained about) added $600 
billion to the short-term deficit and as much as $7.8 trillion in the 
out years. Fiscal conservatives have much more reason to protest that 
legislation than this.
  There is a legitimate concern about whether the so-called ``doc fix'' 
should have been included in this legislation. It is not. That issue is 
the result of the 1997 Balanced Budget Act formula that limits the 
growth of physician reimbursement under Medicare. Since 1997, some 
doctors have been able to increase their reimbursement more than 
others, but all are now threatened with a 21 percent cut. This is a 
$320 billion problem over the next 10 years, and a $4.2 trillion 
problem in the out years. Unless this issue is resolved, it could have 
more deficit impact than all of health reform. I think that we must 
figure out a way to pay for the ``doc fix'' now, not add it to the 
deficit. If you really care about the deficit, watch how your elected 
officials vote on this key issue.
  This legislation does not do enough to contain medical inflation, but 
it makes a good start because it contains the largest proposed savings 
in health costs in history, $600 billion over ten years. To make these 
savings stick, we will all have to be vigilant because every health 
care provider will immediately be asking for Congress to reduce or even 
reverse those savings. For those who sincerely want Congress to have 
more backbone on these issues, the answer is to support more savings 
now by asking for tougher follow-on legislation. You won't achieve more 
savings by encouraging Congress to slouch away from its 
responsibilities today.
  There are many talking heads on television who claim to want more 
cuts, but their immediate plan is to do nothing. Today the official 
Republican Party position is to scare seniors about Medicare and, 
despite a blizzard of words, do nothing. They are behaving as badly as 
the Democratic Party used to behave

[[Page 4191]]

when scaring Social Security recipients. If history is any guide, 
America only has the political will to face up to these issues every 15 
years, and, when we did address them, Congress did not make much 
progress. Neither political party will tell you that the real cost of 
delaying reform is roughly $16 billion a day. That's my estimate, based 
on accrual accounting, of the financial harm being done to America by a 
failure to resolve these problems on a timely basis. Waiting too long 
to pass reform could be as terrible a fiscal tragedy as waiting too 
long to treat cancer. Of course, the pundits have no way of paying for 
the delay, and the fiscal harm, that they foster. The opportunity cost 
of endless arguments may even be greater than the cost of solving the 
problems themselves!
  Opponents of today's reform also claim to have a better plan. I'd 
love to see it. I am thoroughly familiar with their legislative ideas 
because I have been working in a bipartisan way on these issues for 
many years. They simply do not have a better plan today that could 
garner more than a handful of votes, and, given their track record, are 
not likely to ever present one. There is no magic wand. For example, 
I've tried for many years to promote the bipartisan Healthy Americans 
Act, H.R. 1321. We ended up with only a handful of cosponsors. Another 
example is my friend Rep. Paul Ryan's (R-WI) interesting plan that has 
made him the darling of The Wall Street Journal. His bill, H.R. 4529, 
has exactly 13 cosponsors. You need at least 216 votes to get anything 
accomplished. As intriguing as some of these ideas are, they are not a 
solution, especially when the meter is ticking at about $16 billion a 
day.
  There is a lot of rhetoric about which political party is more 
sincere about deficit reduction. The facts are that the last Democratic 
president to have a balanced budget was Bill Clinton, just ten years 
ago. The last Republican president to have a balanced budget was 
Herbert Hoover, almost eighty years ago. Today's Congress has finally 
passed into law important ``pay-as-you-go'' legislation that will force 
Washington to start living within its means. Budget experts think that 
this is the single most important step toward getting our fiscal house 
in order. Blue Dog Democrats, of which I am a member, forced this 
improvement in budgeting.
  The President has created a bipartisan Fiscal Responsibility 
Commission that will help Washington face up to its deficit problems. 
The President is doing his best to implement my bipartisan legislation 
on this issue, legislation that the Senate failed to pass because seven 
Republican senators (who are original cosponsors) voted against their 
own bill! None of these important steps toward fiscal sanity was 
allowed under the previous Administration. In fact, the previous Vice 
President, Dick Cheney, was famous for saying, ``Deficits don't 
matter.'' He could not have been more mistaken.
  Regardless of what happens to this legislation today, America cannot 
afford to ignore the growing crisis in financing today's medical 
system. In the future, we need to focus on these issues every year, not 
every 15 years. Passage of this legislation is absolutely certain to do 
that. Flaws will need to be corrected, adjustments made, new ideas 
explored. I have a list ready. Just as continual advances in medicine 
must be made, continual advancements in delivery of medical care must 
be made. Both types of advancements save lives. It is better when the 
private sector makes these improvements but, when the private sector 
fails, then government should help the private-sector, not run their 
businesses for them.
  I am well aware of the fact that this is a big vote, and perhaps a 
career-limiting decision. But I think most folks back home want me to 
do what is right, not just what's temporarily popular. That's what my 
90-year-old mother taught me. I've made tough votes before and been 
proven right. Against united Republican opposition, I voted for the 
1993 Clinton budget that put America on the path to the longest 
economic recovery in history. Against united Republican leadership, I 
voted against the 2003 Medicare drug bill that was the largest unfunded 
expansion of entitlement programs in history. And against united 
Republican opposition, I voted for the House health reform bill in 
November of 2009 that enabled us to vote on the much better Senate 
measure today.
  I have the honor of representing the Hermitage District. Our greatest 
hero, Andrew Jackson, said ``One man with courage is a majority.'' I 
sure hope he was right.
  Mr. TOWNS. Mr. Speaker, today the House of Representatives is 
preparing to vote on historic health insurance reform legislation, H.R. 
4872, the Health Care and Education Affordability Reconciliation Act. 
We have spent more than a year debating this important bill that will 
provide 32 million Americans health insurance. In my home district, New 
York's 10th Congressional District, access to affordable health 
insurance will make a tremendous difference in the lives of men and 
women who have been burdened by the escalating costs of health care.
  We can no longer wait to stem the rising tide of the uninsured and 
underinsured, implement important reforms to prevent insurers from 
discriminating against persons with pre-existing conditions and enact 
important measures to rein in costs.
  When this bill is signed into law, millions of Americans who do not 
have health care today will finally walk the pathway to coverage. 
American families will no longer face bankruptcy when a loved one gets 
ill and seniors will finally get relief from the high cost of 
prescription drugs due to our expanded coverage under Medicare Part D.
  Importantly, we are doing all of this without adding one penny to the 
federal deficit. In fact, this bill will reduce our federal debt by 
$143 billion over the next ten years, and hundreds of billions more in 
the years thereafter.
  Health insurance reform is an issue I have been committed to 
throughout my long congressional career. We have been close to this day 
before, but this time, at long last, I am confident we will see this 
legislation signed into law.
  Mr. Speaker, I thank my colleagues who supported this bill.
  Mr. ANDREWS. Mr. Speaker, I rise today in support of millions of 
individuals throughout our country who are working for small businesses 
which are in PEO arrangements. The clear objective of this legislation 
is to create incentives for health care coverage and not to provide 
disincentives. I would like to clarify that for purposes of the 
application of section 2716 of the Public Health Service Act 
(Prohibition on Discrimination in Favor of Highly Compensated 
Individuals) and Internal Revenue Code section 45R (Credit for Employee 
Health Insurance Expenses of Small Businesses), to any health plans 
sponsored by a professional employer organization (PEO) or a PEO client 
organization, the rules would be applied to each client organization 
separately and eligibility for the small business tax credits would 
also apply to each client organization separately, and not at the PEO 
level.
  Mr. KIRK. Mr. Speaker, I rise today in opposition to H.R. 3590, the 
Senate Health Care bill. I strongly support reforms to lower the cost 
of health insurance and cover Americans with pre-existing conditions. 
That is why I authored the Medical Rights and Reform Act, H.R. 3790. 
Under our centrist Reform Act, we cover Americans with pre-existing 
conditions and advance three major reforms:
  (1) The Medical Rights Act: Under our bill, Congress shall make no 
law interfering with the personal decisions that you make with your 
doctor,
  (2) Lawsuit Reform: By applying the lawsuit reforms (recently 
eliminated in Illinois) similar to successful California reforms, we 
could reduce defensive medicine, saving over $200 billion annually, and
  (3) Granting Americans Interstate Rights: Our bill grants the right 
to all Americans to buy health coverage from any state in the union, 
especially if you find a plan that is less expensive or more flexible 
for your family or small business. This improves choice and competition 
for each American.
  Unfortunately, the Congressional leadership will not permit a debate 
on our bill. Instead, the House will only allow one vote on the health 
care bill adopted by the Senate.
  Under the Senate bill, the Congress will increase spending by $1.2 
trillion, including $940 billion for new subsidies, $144 billion for 
new mandates, $70 billion to administer the bill and $41 billion in 
unrelated spending. To attempt to pay for the bill, Congress will raise 
taxes, cut Medicare and borrow a historic amount of money. To pass the 
Senate, the bill also included the ``Louisiana Purchase'', ``Cornhusker 
Kickback'' and ``Gatoraide'' that advantaged Louisiana, Nebraska and 
Florida over the people of Illinois.
  The bill imposes 12 new federal taxes, imposing over $500 billion in 
new payments to the government, including over $23 billion in taxes on 
the people of Illinois. Among the new taxes is a new ``Individual 
Mandate Tax'' (IMT) of $2,250 per household or 2 percent of household 
income. The bill increases the Medicare payroll tax and does not adjust 
this for inflation. Therefore, like the infamous Alternative Minimum 
Tax (AMT), the new Medicare tax will soon reach most middle class 
families as inflation pushes more Americans into its bracket.
  The bill also increases the capital gains tax. Most economists worry 
that too many businesses plan for the short-term, hurting long-term 
economic growth. That is why investments which are held for longer 
periods of

[[Page 4192]]

time pay a lower capital gains tax. The Senate bill reverses this wise 
policy by imposing a new 3.8 percent tax on capital gains, raising the 
rate from 15 percent to 23.8 percent by 2013.
  Both Americans for Tax Reform and the Heritage Foundation estimated 
that the new taxes and Medicare cuts in the bill would cost over 
600,000 job opportunities per year or an estimated 26,042 fewer 
Illinois jobs. The bill also has a number of budget gimmicks to hide 
spending. Once the Social Security Trust Fund, long-term health care 
and student loan gimmicks are removed, the bill adds $755 billion to 
the federal deficit or $2,460 in new debt for each man, woman, and 
child.
  Here is a look at the estimated national job losses under the bill:

------------------------------------------------------------------------
                           Sector                                Jobs
------------------------------------------------------------------------
Agriculture, forestry, fishing and hunting..................      -5,441
Mining......................................................      -5,478
Construction................................................     -43,316
Manufacturing...............................................    -105,229
Wholesale trade.............................................     -47,663
Retail trade................................................     -84,339
Transportation and warehousing..............................     -36,806
Utilities...................................................      -5,271
Information.................................................     -26,342
Financial Activities........................................     -77,269
Professional and business services..........................    -132,596
Educational services........................................     -32,102
Leisure and hospitality.....................................     -49,682
Other services..............................................     -46,564
------------------------------------------------------------------------
    Total...................................................    -698,098
------------------------------------------------------------------------

  Half of all people employed in Illinois work in a small business and 
over 80 percent of job losses during this Great Recession have been 
from small business employers. Nevertheless, this legislation requires 
the federal government to levy a new $52 billion tax on small 
businesses, even though unemployment now tops 12 percent in Illinois. 
The bill begins a new $2,000 tax on small business with over 50 
employees. Over 21,600 small businesses in Illinois could be subject to 
this new tax. This tax applies to part-time as well as full-time 
workers. The follow-up Reconciliation Bill also includes an 
unprecedented extension of the Medicare tax to all non-wage income.
  The legislation stands for the principle that we should cut senior 
health care under Medicare to fund a new entitlement spending program. 
Over 40 million seniors depend on Medicare for their health care. Under 
the Senate bill, the federal government would cut over $500 billion 
from Medicare. This includes cutting over $200 billion from Medicare 
Advantage, cancelling the Medicare choice of over 120,000 Illinois 
seniors.
  Here is a summary of the Medicare cuts:

------------------------------------------------------------------------
 
------------------------------------------------------------------------
Medicare Advantage........................  $202 billion.
Home Health...............................  39 billion.
Medicare Part B...........................  25 billion.
Hospital DSH Payments.....................  25 billion.
Medicare Part D...........................  10 billion.
Medical Imaging...........................  1 billion.
Preventative Services.....................  700 million.
Durable Medical Equipment.................  1 billion.
Power-Driven Wheelchairs..................  800 million.
Hospice...................................  100 million.
Medicare Improvement Fund.................  20 billion.
Medigap...................................  100 million.
------------------------------------------------------------------------
    Total.................................  $523 billion.
------------------------------------------------------------------------

  While the American people overwhelmingly want to lower health 
insurance costs, the bill increases costs because it requires Americans 
to buy health insurance that include new mandates for coverage. 
According to the Administration, individual insurance premiums will 
increase by 10 percent for over 600,000 people in Illinois. On average, 
Illinois individuals currently pay $2,499 annually for insurance. Under 
the bill, costs will go up at least $150 a month to a level of $4,299 
annually.
  On March 4, the Chicago Tribune reported that for ``more than half-
million consumers in individual health plans, base rates will go up 
from 8.5 percent to more than 60 percent.'' The non-partisan 
Congressional Budget Office reported that the bill's provisions that 
double the tax on health insurers, drug makers and medical devices will 
all be passed on to patients in the form of higher health costs and 
rising insurance premiums.
  Under the federal Medicaid program for the poor, states must pay half 
of all costs. As you know, the State of Illinois has one of the highest 
deficits of any state, totaling over $12 billion. Spending on the 
Illinois Medicaid program rose 65 percent from $8 billion in 2001 to 
$13 billion in 2008 to now cover 2.4 million people. Under the Senate 
Health Care bill, Illinois would have to cover an additional 400,000 
people, adding an additional $1 billion to the state's deficit over 
five years.
  Health care under Medicaid is already deteriorating. Over 9,000 
doctors in Illinois refuse to accept Medicaid patients (28 percent 
nationwide), in part because it takes Illinois over 100 days to pay for 
services.
  About the only jobs created by the legislation would be at the IRS. 
According to the nonpartisan Congressional Budget Office, the IRS would 
need to hire over 16,000 people--over 700 just in Illinois--to audit 
the American people and impose the new taxes and mandates of the bill. 
New IRS agents would verify if you have acceptable authority, fine you 
up to 2 percent of your income for failure to prove that you have 
purchased ``minimum essential coverage,'' confiscate your tax refund 
and conduct audits. Under the bill, nearly half of the new individual 
mandate taxes will be paid by Americans earning less than $66,150 for a 
family of four.
  I will vote against this legislation because it costs Illinois jobs, 
raises taxes and deepens the debt our children must one day pay. I wish 
that we could adopt a more modest set of reforms that do not have such 
harsh consequences for our economy.
  In the coming days, I will outline policies and legislation that will 
reduce spending, lower the debt and prevent new taxes on the American 
people. While we did not prevail in this contest, I will continue to 
work and ensure a strong economy and bright future for every Illinois 
citizen.
  Mr. GRIJALVA. Mr. Speaker, after a long battle for this Nation's 
health care reform, my decision to vote in favor of this bill was 
ultimately made, not by myself, but by the people I represent.
  This bill is a beginning to the end of an abusive system:
  It is a beginning to provide the people of our great Nation access 
the most basic health care services;
  It is a beginning to stop insurance companies from reaping benefits 
at the cost of the sick, injured, poor and dying people in our Nation;
  It is a beginning to making our health care system one that we can be 
proud of--
  One that includes everyone regardless of their social status;
  One that treats people equal regardless of their age, race or gender;
  One that makes sure our children are treated properly and that our 
parents will be provided for in the future; and
  It finally provides reauthorization of Indian Health Care.
  Every day I am flooded by groups, businesses and individuals that can 
no longer bear the abuses from our current health care system. I want 
to share of few of their reasons for supporting this bill:
  The National Committee to Preserve Social Security and Medicare 
states:

       The bill preserves and improves Medicare for current and 
     future beneficiaries. Because of our strong commitment to 
     Medicare, we support the health reform currently before 
     Congress. Indeed, we consider it to be vital for preserving 
     and protecting Medicare. On behalf of the seniors you 
     represent, we ask that you commit to supporting health reform 
     as well.

  Catholic Sisters for Healthcare Reform states:

       We have witnessed firsthand the impact of our national 
     health care crisis, particularly its impact on women, 
     children and people who are poor. We see the toll on families 
     who have delayed seeking care due to a lack of health 
     insurance coverage or lack of funds with which to pay high 
     deductibles and co-pays. We have counseled and prayed with 
     men, women and children who have been denied health care 
     coverage by insurance companies. We have witnessed early and 
     avoidable deaths because of delayed medical treatment.

  American Nurses Association states:

       We understand the cost of inaction--our patients can no 
     longer afford to wait. The uninsured and underinsured 
     continue to delay or forgo much-needed care; they continue to 
     arrive in the emergency rooms across the country for 
     conditions that could have been easily prevented with access 
     to primary care--we are all paying a high price for inaction.

  My dear friend, Karen, from the National Breast Cancer Coalition came 
to me and poured her heart out on behalf of the millions of women 
battling cancer, this vote is for you. The National Breast Cancer 
Coalition states:

       For women who are battling breast cancer, health care 
     reform will mean accessing potentially life-saving treatment 
     and not losing their health insurance coverage if they lose 
     their job. For their families, it means not being driven into 
     bankruptcy when the person they love has been diagnosed with 
     breast cancer, must contend with a recurrence of the disease, 
     or struggle with equally life threatening complications. For 
     the tens of thousands of women who will be diagnosed with 
     breast cancer today and in the future, enacting health care 
     reform will mean being able to focus their energy on battling 
     the disease, not fighting with their insurance company. We 
     cannot delay any longer.

  United States Hispanic Chamber of Commerce states:

       As business owners, we know well the concept of opportunity 
     cost. The rate of premium growth has become such a burden to 
     our businesses that we are required to support this 
     compromise rather than see premiums double, or triple, once 
     again as they

[[Page 4193]]

     have done this decade. As organizations that believe in free 
     market solutions, this decision was not taken lightly. But, 
     the fact remains that the small business components in this 
     compromise bill will provide real relief--a small business 
     exchange that pools risk while respecting the free market and 
     tax credits to incentivize those businesses that are just 
     within reach of providing health care to their workers.

  While these groups and the American people understand this bill is 
the beginning of reforming our system, I can assure you it is not the 
end.
  I will continue to fight for a public entity to be part of our 
system.
  I will continue to fight for immigrants to be treated fairly in our 
Nation, and I will argue the grave economic impacts of leaving these 
people out of our system.
  I will continue to fight for stricter control of the pharmaceutical 
companies to force them to negotiate prices instead of dictating them.
  And above all I will not stop, I will continue to push to make our 
system more efficient and more equitable--this is only the beginning.
  I would like to end with a quote from my dear friend that we lost 
during the mist of this battle, who I feel has been our guiding light.
  Ted Kennedy said:

       The battle to achieve Medicare for All will not be easy. 
     Powerful interests will strongly oppose it, because they 
     profit immensely from the status quo. Right wing forces will 
     unleash false attack ads ranting against socialized medicine 
     and government-run health care.

  Ted--we will not give up--this is the beginning.
  Mr. FRELINGHUYSEN. Mr. Speaker, at the outset, let me be very clear: 
I support health care reform. I just do not support Speaker Nancy 
Pelosi's version of health care reform.
  With respect to controlling costs for New Jersey's families, changing 
insurance company practices and making coverage more available to more 
Americans, the status quo is simply unacceptable. We can, and we must, 
do better, but not at the expense of millions of American families who 
are worried about a government takeover of their health care decisions!
  With that said, the health care package before the House today is 
wrong on both process and policy.
  On process, the American people know instinctively that a change as 
historic as this will only be successful with full engagement of the 
American people and bipartisan support in Congress. However, from the 
beginning, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid 
adopted a `go-it-alone' strategy and refused to consider Republican 
ideas in any significant way. Indeed, the Majority today is even 
refusing to listen to the very valid concerns of the American people.
  In addition, this legislation, and all the versions that preceded it, 
were drafted behind closed doors at the White House or in Capitol 
backrooms, with no transparency whatsoever as to which organizations 
were participating and benefitting! In fact, the Majority had to be 
`shamed' into releasing the contents of the bill 72 hours before a vote 
to allow Republicans and the American people to review its contents.
  To add insult to injury, the President and Speaker Pelosi decided to 
use the budget 'reconciliation' process solely to deny the Senate 
Minority the ability to use its traditional practice of the filibuster 
to block passage of harmful legislation such as this.
  Madame Speaker, the process the Majority has used is shameful, but 
the policy they seek to impose is downright harmful.
  Once again, I state without hesitation that I support health reform. 
However, I cannot support this proposal.
  First, this package contains over $523 billion in job-killing, higher 
taxes. I cannot think of a worse time to tax families and small 
businessmen and women than in the middle of a serious recession.
  The American people need to understand the destructive nature of this 
bill: $17 billion in new taxes on Americans who do not obey the bill's 
requirement that individuals must buy health insurance whether they 
want to or not, and $52 billion in new taxes on employers that do not 
provide health coverage deemed ``acceptable'' or ``affordable'' by 
Washington-based government bureaucrats. This provision alone may force 
the IRS to hire another 16,000 agents and auditors to enforce 
compliance with the new law.
  In addition, the bill contains new taxes on capital gains, dividends 
and interest that will further stifle economic growth and job creation. 
The Medicare tax on capital gains, dividends, and other investment 
income gets bigger, magnifying the destructive power of the tax. The 
bill increases the tax from 2.9 percent to 3.8 percent and for the 
first time, this tax will be extended beyond wages to include interest, 
dividends, capital gains, annuities, royalties, home sales and rents. 
This new tax will be particularly damaging to New Jersey's seniors, 
many of whom depend on such income to survive.
  Second, this package contains over $569 billion in total cuts to 
Medicare.
  These reductions include $202.3 billion from seniors' Medicare health 
plans, including massive cuts targeting the extra benefits and reduced 
cost-sharing seniors receive through Medicare Advantage. 148,000 
seniors in New Jersey, including over 35,000 in my Congressional 
District enjoy the benefits of this innovative program. The 
Congressional Budget Office predicts that three million seniors 
nationwide currently receiving health benefits through these Medicare 
plans will be dropped.
  But the Medicare cuts go deeper. The bill slashes $156 billion from 
hospitals, including long-term care hospitals, skilled nursing 
facilities, Ambulatory Surgical Centers, hospice, ambulances, dialysis 
facilities, labs and durable medical equipment (DME) suppliers.
  The package also contains $40 billion in cuts to home health 
reimbursements and $22 billion in additional cuts to hospitals by 
slashing reimbursements designed to assist hospitals that serve low-
income patients. In addition, $65.7 billion in money will be taken from 
seniors in the form of higher premiums.
  My colleagues, I am also shocked that the Majority has not protected 
our men and women in uniform, military retirees and veterans who could 
be affected by the new law. The Senate-passed health care bill omitted 
protections for military health plans that were included in the House 
bill.
  Specifically, the Senate language does not appear to give the 
Department of Veterans' Affairs (VA) health care system specific 
protection from interference by other government agencies administering 
the various authorities contained in the massive bill, as it pertains 
to ``minimum essential coverage.''
  Further, the final bills would leave it up to bureaucrats at the 
Department of the Treasury to determine whether TRICARE meets the 
minimum standards under the bill's individual health insurance mandate. 
If that bureaucrat decides against TRICARE, service members and their 
families would have to buy some other health coverage or pay a penalty.
  Our men and women in uniform, and our veterans, have earned the best 
health care available. They need to know that they will continue to 
receive this same level of care. It is truly regrettable that, in a 
bill stuffed with `backroom' deals and special `arrangements', this 
group of American heroes is denied the consideration they earn on the 
battlefield each and every day.
  Mr. Speaker, this bill is also notable for what it does not contain. 
There is no medical lawsuit reform. It fails to promote portability of 
coverage. It does not allow insurance companies to sell their policies 
across state lines. It fails to recognize the value of Association 
Health Plans, which permit small businesses to pool their risk in order 
to secure lower insurance rates. The bill does not expand Health 
Savings Accounts which millions of families use to provide protection 
against catastrophic illness or injury. The package also does very 
little to enhance medical training for doctors, nurses and technicians. 
If we are going to expand coverage for tens of millions of Americans, 
we need to increase graduation rates in these critical medical 
professions.
  I would also add that this bill completely ignores the ongoing crisis 
in Medicare reimbursement rates for doctors. My colleagues, the 
question is not whether you can choose your doctor under the Pelosi 
health care proposal, but whether your doctor will choose you! Many 
doctors in New Jersey are already questioning their participation in 
the Medicare program, putting in greater jeopardy our seniors' access 
to care. Does the Majority actually believe that the pending 22-percent 
reimbursement reduction will not cause more doctors to `opt out' of 
Medicare?
  Mr. Speaker, I end this statement where I started: I support health 
care reform. The status quo is unacceptable and I would welcome the 
opportunity to work with anyone who will work with me to draft and pass 
single, individual bills that promote portability of coverage, allow 
individuals to buy health care across state lines, cover people with 
preexisting conditions, improve access to Health Savings Accounts, and 
enact `junk lawsuit' reform, among other actions to bring down the cost 
of coverage for New Jersey families and businesses.
  We can do better than this process and this package. America's future 
economic and security freedoms depend on it.
  Mr. TAYLOR. Mr. Speaker, I voted against H.R. 3962, the Affordable 
Health Care for America Act, on November 7, 2009 and I will continue to 
oppose this legislation in the House. The House passed the bill by a 
vote

[[Page 4194]]

of 220-215. During House consideration, I voted for the Stupak 
amendment, which prohibits federal funds from paying for abortions or 
from subsidizing health insurance plans that would cover abortions. The 
House passed the Stupak amendment by a vote of 240-194.
  Taxpayers cannot afford a new federal health insurance program. The 
government already provides Medicare, Medicaid, and other programs to 
provide medical care for senior citizens, people with disabilities, and 
others who have substantial medical needs. Our nation also has an 
obligation to provide medical coverage for veterans, active-duty 
military and their dependents, National Guard and Reserve personnel, 
and military retirees. With the national debt in excess of $12 trillion 
and projected to grow far into the future, I believe that Congress 
should focus on fulfilling the promises that have already been made 
rather than make new promises that we cannot afford.
  There are several ways to make health care more efficient without 
increasing costs and without creating a whole new government program.
  I strongly support efforts to allow the government to use their 
purchasing power to negotiate directly with drug manufacturers when 
buying prescription drugs for beneficiaries enrolled in the Medicare 
Part D Program. Negotiating prices with insurance companies would help 
to ensure that taxpayers are paying the best available price and that 
tax dollars are spent wisely without reducing coverage or affecting the 
individuals enrolled in Medicare Part D. In 2008, the government spent 
about $49 billion on Medicare Part D drugs. If the government could 
save even 10% by negotiating directly with drug companies, taxpayers 
would save nearly $4.9 billion.
  The government should purchase generic drugs instead of more 
expensive alternatives, unless the prescribing physician says that a 
name brand drug is medically necessary. On average, generic drugs cost 
1/10th of the cost of their name brand equivalent.
  I am a cosponsor of H.R. 1583, legislation to repeal the insurance 
industry's antitrust exemption. The health care bill that passed the 
House included a repeal of antitrust laws only for the health care 
industry. While this is important, I firmly believe that repealing 
antitrust laws from the entire insurance industry would force insurers 
to compete with one another in a competitive market on the basis of 
price, service, and value. I strongly supported the bill that passed in 
the House which repealed the exemption of antitrust laws for the health 
care insurance industry.
  I am also in favor of proposals that would allow individuals to 
continue to be covered under their parents' insurance plan until they 
reach the age of 27.
  I would like to remind you that I do not support creating a whole new 
health care program, but I do support smaller reforms to make the 
current system more effective for taxpayers and consumers. Again, I 
voted against the health care bill that passed the House, and I will 
oppose this bill.
  Mr. MORAN of Virginia. Mr. Speaker, today we will define who we are--
as Americans, and as Democrats or Republicans.
  No Republican will vote for this bill because they say they want a 
smaller government, lower taxes, and less spending.
  Democrats, on the other hand, believe that America's government can 
be fiscally responsible and also play an essential role in helping 
America achieve its true greatness.
  We know that America is a lesser Nation when we have to pay twice 
what other countries citizens' pay for health care, while we live 
shorter and less healthy lives; We are a lesser nation when millions of 
America's families lose their homes and life savings because a loved 
one gets seriously sick.
  We know that we can reduce the suffering of our people, while 
lengthening and bettering their lives. And because we know this, we 
have a responsibility to change it.
  As with Social Security and Medicare and Civil Rights legislation, it 
is now time for another step in our historic progress toward greatness. 
That's why we chose public service and why we, as Democrats, will pass 
this bill today.
  Mr. CROWLEY. Mr. Speaker, I rise in support of the Patient Protection 
and Affordable Care Act, a historic measure that will put families 
first when it comes to accessing health care coverage.
  American families need this bill now more than ever. In the past 
decade, the cost of health care for American families has skyrocketed. 
Last year, more than half of Americans postponed care or skipped their 
medications because they could not afford it.
  If we do nothing, it is only going to get worse.
  If we do nothing, in ten years small businesses will shell out 
$29,000 in medical costs per employee--a staggering 166 percent 
increase.
  If we do nothing, the cost of an employer-sponsored health insurance 
plan will reach $24,000 a year by 2016--an outrageous increase of 84 
percent.
  And if we do nothing, the American economy will break under the 
weight of mounting debt.
  Just saying no and doing nothing is not an option. And yet, some of 
my colleagues on the other side of the aisle continue to tell us 
exactly that--stop, do nothing, things are okay as is.
  But, Americans know that the current situation is neither okay nor 
sustainable. Americans may be tired of the endless media coverage 
regarding this debate. And, they might be frustrated by the lack of 
cordiality between Republicans and Democrats. But, they know that we 
have serious problems in our health care system that must be fixed.
  And we are ready to do it.
  The Democratic Congress, along with President Obama, has put together 
a reform measure that will put an end to abuses in the insurance 
industry and mandate that patients' needs be put first.
  When the President signs this measure into law, immediately:

  Insurance companies will no longer be able to deny coverage to 
children who are sick or end coverage for Americans who get sick;
  Children and young adults will be allowed to remain on their parents' 
insurance plans up to the age of 26--helping them stay healthy during 
this important transition period;
  Seniors who currently have a gap in their prescription drug coverage 
will see the cost of their brand name drugs reduced by 50 percent and 
the gap in their prescription drug coverage reduced by $250. In the 
coming years, all gaps in coverage will be eliminated entirely.

  Beyond the immediate benefits, many other important reforms will go 
into effect within a few years:

  There will be stability and security for those who have health 
insurance. So, if you like the coverage you have currently, you can 
keep it.
  Small businesses will qualify for generous tax credits to help offset 
the cost of insuring their employees and keep them competitive in the 
global economy;
  The growth in medical costs will go down, as will the Federal 
government's deficit.

  Simply put: health reform is good medicine for American families and 
businesses.
  There's no doubt that this reform measure isn't perfect. But, like 
any significant change in policy, it will always be a work in progress. 
We will make changes as we move forward. There is no denying, however, 
that today's vote is historic and significant and will benefit millions 
of hard-working American families.
  Mr. Speaker, it is time for courage. Former President Franklin D. 
Roosevelt once said ``The only limit to our realization of tomorrow 
will be our doubts of today. Let us move forward with strong and active 
faith.''
  We must not be afraid of tomorrow, when today we can change the lives 
of millions of Americans for the better.
  I urge my colleagues to vote ``yes'' and join us in the effort to put 
the health of Americans before insurance company profits.
  Mr. McCAUL. Mr. Speaker, in a desperate effort to pass a sweeping 
government takeover of our health care system, Democrats held Congress 
in session throughout the weekend to pass H.R. 3590, The Patient 
Protection and Health Care Affordability Act along with a package of 
desired ``fixes,'' H.R. 4872, The Health Care and Education 
Affordability Reconciliation Act. In a purely partisan fashion, the 
Democrats have now passed the largest tax increase in history, a 
massive expansion of entitlements, and policies which will put the 
health care system at the whim of the Federal Government.
  One of the most distressing aspects of this legislation is the 
dishonesty which has been utilized for its passage. While I am pleased 
that the Democrats forfeited the ``Deem-and-Pass'' ploy to hide a vote 
on the Senate health care bill, I am shocked that they support this 
2,700 page monstrosity, complete with its slew of sweetheart deals that 
benefit home states of members who once opposed the bill. Despite the 
backlash that rightfully followed these deceitful kickbacks, the 
Democrats included even more million-dollar deals for specific members 
in the reconciliation package. This tactic is an abuse of power, an 
abuse of taxpayer money, and abandons the integrity that the American 
public expects from their Congress.
  The numbers in this Democratic health care package are astounding. 
The bill costs about $1.2 trillion over the next ten years, imposes 
almost $570 billion in new taxes on the American public, and cuts the 
Medicare program by over $500 billion. As our economy attempts to 
recover from the largest recession since the

[[Page 4195]]

Great Depression, this bill's laundry list of new taxes is deplorable: 
$32 billion in taxes on health care benefits, $52 billion in taxes on 
employers, $17 billion in penalties on individuals, $210.2 billion in 
an unprecedented Medicare tax on wages, self-employment income, and 
certain investment income, and many more. While these taxes will be in 
effect immediately, 98% of the bill's provisions do not begin until 
2014. Therefore, Americans will be paying for health reform for four 
years without ever seeing the government return the favor. 
Unbelievably, the bill's true ten-year cost when fully implemented 
totals about $2.4 trillion dollars. To pay for this spending, it 
proposes half a trillion in cuts to Medicare and Medicare Advantage, 
robbing the benefits our seniors deserve.
  What may be worse than the vast cost of this bill are the budgetary 
gimmicks used in its scoring. The authors use ten years of revenue to 
pay for only six years of government spending. They also double count 
savings from Medicare cuts to simultaneously pay for Medicare 
entitlements and the bill's new entitlements. Furthermore, the bill 
does not include the ``doc fix,'' legislation that will likely be 
passed separately to ensure doctors do not incur a huge cut in 
reimbursements--and costs an additional $371 billion. These methods 
were used to dupe the American people, a smoke-and-mirrors strategy to 
uphold President Obama's pledge that health care reform will ``not add 
a dime to the deficit.'' Unfortunately, if one omits these budgetary 
tricks from the bill's cost, it will actually increase the deficit by 
almost $600 billion in the first ten years.
  The structure of this bill is a clear effort to give the government 
complete control over health care--it takes choice and flexibility from 
American citizens while also making them pay more. For example, the 
bill instructs the Health and Human Services (HHS) Secretary to 
determine what constitutes a ``minimum benefits package'' for all 
Americans and then requires all citizens to purchase it. This mandate 
will be enforced by a massive expansion of the IRS, which will fine 
those who do not comply two percent of their income. I believe that 
individuals can best determine for themselves how comprehensive their 
health care insurance should be, and that Americans have many different 
needs which cannot be defined by a one-size-fits-all package. 
Unfortunately, H.R. 3590 sets the stage for mandated, standardized 
health care.
  The provisions in H.R. 3590 will hurt families, businesses, and kill 
jobs at a time when we can least afford it. The Congressional Budget 
Office (CBO) has reported that this health care package will most 
likely raise premiums for millions of families by $2,100 per year. It 
also taxes employers if they cannot provide health insurance and their 
employees receive federal subsidies--this provision will cause 
employers to lay off employees due to cost increases, and it 
discourages companies from hiring low-wage workers who are more likely 
to qualify for subsidies. Furthermore, Democrats have promised that 
Americans may keep their health insurance if they like it, but the CBO 
has predicted that up to 9 million Americans will lose their employer-
based coverage. Additionally, the bill imposes an unfunded mandate on 
Texas by drastically expanding the Medicaid program, costing Texas an 
estimated $24.3 billion dollars in the next ten years.
  Unfortunately, the reasons why this bill will hurt this country 
abound. This legislation fails to ensure federal funding is not used 
for elective abortions. While the President has promised to issue an 
Executive Order for political effect, the President cannot amend a bill 
by issuing an order, and the federal courts will enforce what the law 
says. The bill also fails to include proper verification procedures to 
ensure illegal immigrants do not receive federal subsidies to purchase 
health insurance. Furthermore, it lacks protections for 9.2 million 
military personnel, families and retirees that their health insurance 
will not be affected. These pitfalls explain why Americans have flooded 
the DC area in protest, a visual testament of the public opinion on the 
Democratic health bill, which has become largely opposed throughout the 
debate. Unfortunately, the Democrats have not listened, and in one of 
the largest abuses of majority power, have forced their hand on the 
American public.
  My fellow Republicans and I have been willing to work on health care 
reform from the beginning of this debate. We have introduced numerous 
proposals emphasizing free market solutions and cost-cutting strategies 
to make health care insurance readily available and more affordable to 
Americans. We were present when the President called us to discuss 
health care reform, but our willingness to start over and work together 
was ignored by our colleagues. I am disappointed by the events of 
tonight, but I have not given up and will continue to work for true 
reform that will lower costs instead of simply shifting those costs 
onto the government.
  Mr. SIMPSON. Mr. Speaker, I rise today in opposition to H.R. 3590 and 
H.R. 4872. Passage of this legislation represents the first step to a 
government takeover of our health care system. Everyone agrees that our 
health care system needs to be reformed. Health care in America is too 
expensive and too many families across America are worried about losing 
or have already lost their health coverage. Businesses, small and large 
alike, are struggling to provide health insurance for their employees.
  Unfortunately, rather than working on real reforms to improve access 
to health care for all Americans, Democrats have chosen to pass a 
trillion dollar bill that would raise Americans' taxes, create a 
massive new tax burden, and do little to address the problems in our 
current health system. The frightening reality for the American 
taxpayer and anyone who will need health care in the future is that the 
Democrats are hiding the true costs of these bills and doing so in ways 
that will be disastrous to our Nation's long-term fiscal health. 
Instead of creating another absurdly expensive government program, we 
should work to make health care affordable and accessible for everyone.
  I strongly believe that there are a number of measures that all of 
us, regardless of party affiliation, support that will bring down costs 
and improve access to care for all Americans. These are not new ideas--
they are, however, ideas that are critical to implementing real, 
affordable and effective health reform. First, we must pass effective 
medical malpractice reform. We should end the practice of banning the 
purchase of insurance across State lines, and we should pass 
legislation to allow small businesses to band together through 
associations to buy health care coverage. I also support provisions 
that prohibit insurers from denying coverage to those people with pre-
existing conditions. Further, we need to do more as a country to focus 
on prevention and early intervention. As a dentist, I have seen the 
benefits of prevention and early intervention. We should be focusing 
more on how to prevent disease or treat it early when it is most cost-
effective and the outcomes are best.
  Unfortunately, the Democrats' health reform bill fails to accomplish 
these goals. I am disappointed that President Obama and Speaker Pelosi 
have chosen to ignore the clear message from the American people by 
supporting a massive government takeover of our health system. 
Americans deserve REAL reform--not a partisan, gimmicky bill that will 
cost trillions of dollars and do little to improve care.
  Mr. ROSKAM. Mr. Speaker, I rise in strong opposition to the 
reconciliation procedure that will transform over one-sixth of our 
nation's economy and increasingly cause reliance on the federal 
government for healthcare and education. Beyond my procedural and 
political problems, I have major concerns with the elimination of the 
Federal Family Education Loan program because it will destroy an 
important tool for need-based graduate student aid--the School as 
Lender program. Overhauling the federal student loan program will have 
unintended consequences in the form of lost private sector jobs and 
lost opportunities for graduate students in Illinois' Sixth 
Congressional District. Millions of dollars in financial aid for 
thousands of students across the country will be lost. I also fear the 
program will add to our nation's already record deficit.
  Procedurally, the proposal has not received a hearing or markup in 
the United States Senate. At least nine Democrats in the Senate have 
written with concerns on the proposal's effect on job losses in the 
private sector.
  The elimination of the School as Lender program ignores the needs of 
graduate students. Schools obtain credit to make loans and use the 
proceeds from their origination to support financial aid. Proceeds from 
the sale of loans must be returned to graduate students in the form of 
need-based grants. A 2005 Government Accountability Office (GAO) report 
stated, ``School lenders either used money to lower borrowing costs 
and/or provide need-based grants to its students.'' Without School as 
Lender, many students will now be forced to take out more loans and 
student debt.
  Within my Congressional District, one of the pioneers of the School 
as Lender program, Midwestern University, uses its School as Lender 
program to provide need-based grants to students who would otherwise 
not be able to pursue the University's graduate programs in osteopathic 
medicine, pharmacy, dental medicine and other health sciences. 
Decreasing access to education for low-income students would further 
inflame the shortage of the healthcare workforce as Congress considers 
a massive healthcare takeover. Over the past

[[Page 4196]]

three academic years, Midwestern University has paid out over four 
million dollars in School as Lender scholarship monies to more than 
1,500 students. Midwestern lacks profit motives to continue the 
program--they simply desire to maintain an affordable option to attract 
graduate students.
  Additionally, the savings from the transition to fully federal funded 
student lending has been overpromised and any savings will be 
overspent. Updated Congressional Budget Office (CBO) scores show the 
initiative is projected to increase deficits rather than decrease our 
debt. According to CBO, after evaluating the fair value of providing 
credit assistance to students including the cost of market risk and the 
present value of future administrative costs, the lending overhaul 
increases the deficit even more significantly. The House-passed (H.R. 
3221) measure promises $77 billion in new spending compared to only $40 
billion in savings from the President's proposal. This accounting is 
necessary to factor all of the risks that loans and loan guarantees 
impose on taxpayers and the cost of market risk.
  Through the School as Lender program, Midwestern is able to break 
down cost barriers that keep many low-income students from seeking 
graduate degrees. I urge my colleagues to rise against this overreach 
that would prohibit graduate students from access to a valuable 
scholarship opportunity while further burdening our children with an 
increase to our record national debt.
  Mr. BOOZMAN. Mr. Speaker, we are all here because we want to do what 
is best for our constituents, our State, and our country. All of us in 
this chamber understand the importance of health care reform no matter 
what side of the aisle we sit on. We've all heard stories and know of 
family members, friends and neighbors who aren't able to get the care 
they need at a cost they can afford. Like my constituents and all 
Americans I want reforms that save lives, save money, and improve care. 
Unfortunately, this bill doesn't reach those goals.
  We must remember that we work for the people. I think some of us have 
forgotten who our bosses are. It's not President Obama, Speaker Pelosi 
or Senator Reid, it's the American people. There is no doubt that the 
people have spoken loud and clear against this big government health 
care bill. If you need a reminder, go look out the window of the 
Capitol where you can see the opposition to this bill mounting.
  I urge my colleagues to do what the overwhelming majority of 
Americans want and that is to kill this bill.
  Mr. THOMPSON of Pennsylvania. Mr. Speaker, for the first time in 
history, the House of Representatives will pass a life-changing measure 
without a single Republican vote in favor. That vote will impact one-
sixth of our U.S. economy and affect every man, woman and child in the 
nation, now and for generations to come.
  In almost every poll, the majority of Americans didn't like this bill 
or the manner in which it was placed before the Congress for a vote.
  According to the most recent Gallup Poll, 66 percent of Americans 
think the Democrats' massive government takeover of health care would 
make things worse or make no difference for themselves and their 
families.
  I believe we have started down a path of total government takeover of 
our health care system at a cost of almost $1 trillion now, and untold 
costs to be paid later in taxes, fines and loss of care. As a health 
care professional, my evaluation of the measure is that it will 
decrease access to health care, increase costs, put a bureaucrat 
between you and your physician and place quality care as an 
afterthought.
  I fear the impact on our rural hospitals and I fear this measure puts 
us on a path of no return, which will be spoken about in depressing and 
critical terms for decades to come.
  One hundred and thirty economists wrote to the President March 18th 
to tell him that the Health Care bill is a job-killer. Minority Leader 
John Boehner released the contents of that letter.
  They wrote: ``The bill raises taxes by almost $500 billion over ten 
years. A significant portion of these tax increases will fall on small 
business owners, reducing capital and limiting economic growth and 
hiring.''
  And they wrote: ``The bill will impose a tax of $2000 per employee on 
employers with more than 50 employees that do not provide health 
insurance. The bill will also tax employers that offer health coverage 
deemed `unaffordable' by the government. These new taxes on employers 
will reduce employment or be passed on to workers in the form of lower 
wages or reduced hours.''
  It doesn't take much deduction to figure out that if you have 49 
employees now, you will never hire the 50th employee. Why would you 
bring that burden on your business?
  Those with 53 or 54 employees will potentially fire four or five 
employees in order to go below the mandate.
  The economists concluded, ``The new and higher taxes on America's 
small businesses and workers included in the bill are detrimental to 
job creation and economic growth, especially now given the fragile 
state of the economy.''
  But the bill will create jobs--for the tax collector. Some 16,500 
people will be hired as auditors, agents and other employees needed by 
the Internal Revenue Service to collect the hundreds of billions in new 
taxes. The cost of enforcement is estimated to be between $5 and $10 
billion over 10 years and it is not paid for in the bill.
  The wealthier American people will be taxed to subsidize those who 
cannot afford their health care. And few will be able to afford health 
care as the mandates take shape and insurance companies are unable to 
make a profit under the new rules. The eventual result will be 
rationing of care.
  Rural hospitals already suffer from low reimbursement rates under 
Medicare and Medicaid. Those rates are eighty to ninety cents for one 
dollar of health care value in Medicare and forty to sixty cents for 
one dollar of health care value in Medicaid. When the federal 
government controls the private health care industry as well, no one 
will be paid the full cost of medical care.
  The bill cuts more than $200 billion from the Medicare Advantage 
program.
  Rural hospitals now get by with a one to three percent profit per 
year. If that evaporates, small hospitals will close.
  Republicans have been vocal in their support of the need to fix our 
health care system. We have dozens of bills including the ``Putting 
Patients First Act''--a bill I have co-sponsored. It allows purchase of 
health care across state lines, deals with pre-existing conditions and 
allows parents to keep their children on their health care plans until 
age 26. It does all of this without taxes or cuts in Medicare.
  We could have agreed on a number of issues. Instead, we have more 
than 3,000 pages of Senate bill, reconciliation package and manager's 
amendment that we will be unfolding and deciphering for years to come. 
The undiscovered, perhaps unintended, consequences will be continuing 
surprises.
  For example, according to The Wall Street Journal, Caterpillar Inc. 
announced that the bill will increase its health-care costs by $100 
million in the first year--no doubt giving it, and many other American 
companies, another reason to move American jobs to foreign countries. I 
fear this is the tip of the iceberg.
  Mr. ISSA. Mr. Speaker, as Americans, one of our most sacred and 
fundamental rights is the right to protest that with which we disagree, 
and I am encouraged to see Americans exercising that right by joining 
together at the Capitol to voice their opinion on health care reform. 
The actions of a few individuals, revealed last week in news reports, 
who shouted profane and bigoted language at members of Congress, has no 
place in this debate or any other. These actions are deeply 
regrettable. Across our nation, Americans have engaged in peaceful 
demonstrations all across the country voicing their opinions in 
townhalls, rallies, marches and protests. By engaging in robust, civil 
debate, we honor the highest and best tradition of our democracy.
  Mr. NEUGEBAUER. Mr. Speaker, I rise today to voice my opposition to 
this government takeover of health care. I believe improvements could 
be made to the existing health care system, but this government 
takeover of one-sixth of the economy is not the right answer. It will 
not lower the cost of health care, but will add layers of bureaucracy 
and confusion to the existing system.
  I am not alone in opposing this flawed, irresponsible bill. In the 
past week, more than a thousand constituents from the 19th District of 
Texas have emailed and called me to express their opposition, and 
thousands more have contacted me in opposition since this debate began 
last year.
  My constituents don't understand why the House leadership insists on 
going down the road of trying to enact a government takeover of health 
care that our nation can't afford and that will not improve their 
health care. They don't understand why leaders in Congress refuse to 
listen to the American people. They do not support this expansion of 
government; they do not support their tax dollars funding coverage for 
abortion; and they do not want us to approve this legislation.
  We must ask ourselves whether this legislation advances the principle 
of empowerment or expands entitlement. I strongly believe government 
should empower individuals to be successful in the economy, rather than 
enact policies that make them more dependent on the federal government. 
Our Founders believed in empowerment, but this legislation

[[Page 4197]]

shows how far this Congress has strayed from this principle.
  This legislation clearly expands entitlement and blatantly fails to 
empower Americans. The policies being proposed today will create more 
uncertainty for employers trying to create new jobs, increase costs for 
families and create new unfunded liabilities for the federal 
government. We cannot continue down this path of entitlement; it simply 
does not work.
  This bill increases government spending by $1.2 trillion and 
increases taxes by $569 billion. It also includes unfunded mandates 
that states cannot afford in the form of Medicaid expansions.
  Rather than lowering health care premiums for families by up to 
$2,500, as the Republican plan would do, this bill does nothing to help 
contain rising health care costs--the chief health care concern of most 
Americans. In fact, the Congressional Budget Office reports that the 
reconciliation bill will have a similar effect on premiums as the 
Senate bill, which is to increase insurance premiums for families by 
$2,100 per year compared to passing no bill at all. Up to 9 million 
Americans who currently have health insurance coverage from their 
employer could lose it under this bill.
  I am deeply disappointed that this legislation fails to provide 
robust protection for the unborn and for taxpayers who oppose their 
dollars going toward abortion.
  Over the next 10 years, this legislation will increase the federal 
government's commitment to health care by $400 billion. At a time when 
the federal deficit is $1.5 trillion and the national debt is projected 
to triple by 2020, it is completely irresponsible for Congress to add 
more unsustainable government spending to the tab that our children and 
grandchildren will have to pick up.
  We can make health care more affordable, available and accessible for 
everyone without nationalizing the system, raising taxes and piling on 
the debt. We need to sit down, in a bi-partisan way, and work on real 
reform that will help American families. That is what the American 
people want and what they deserve.
  On behalf of the 19th Congressional District, I stand in strong 
opposition to this legislation. This Congress must do better; the 
American people demand that we do better. We must reject this bill.
  Mr. PASCRELL. Mr. Speaker, in my capacity as co-chair of the 
Congressional Brain Injury Task Force, I would like to share my 
understanding of the intent of the provisions of H.R. 3590, the Patient 
Protection and Affordable Care Act regarding coverage of the treatment 
continuum for persons with brain injury. I believe that health care 
reform should address the unique health care needs of individuals with 
brain injury by recognizing that brain injury is the start of a 
lifelong disease process requiring access to a full continuum of 
medically necessary treatment, including rehabilitation and chronic 
disease management, furnished by accredited programs in the most 
appropriate treatment setting as determined in accordance with the 
choices and aspirations of the patient and family, in concert with an 
interdisciplinary team of qualified and specialized clinicians.
  News reports of returning veterans and recent high profile brain 
injury stories indicate what researchers have been reporting for 
years--brain injury is a leading public health problem in U.S. military 
and civilian populations. Brain injury is not an event or an outcome 
but is the beginning of a lifelong disease process that impacts brain 
and body functions resulting in difficulties in physical, 
communication, cognitive, emotional, and psychological performance that 
undermines health, function, community integration and productive 
living. Brain injury is also disease causative and disease accelerative 
in that it predisposes individuals to re-injury and the onset of other 
conditions (e.g., brain injury impacts neurologic disorders such as 
epilepsy, vision and hearing impairments, psychiatric disorders, and 
orthopedic, gastrointestinal, urologic, sexual, neuroendocrine, 
cardiovascular and musculoskeletal dysfunction).
  The Brain Injury Association of America, BIAA, has developed a series 
of guiding principles for assessing any health reform bill from a brain 
injury perspective. I am pleased to conclude that the Patient 
Protection and Affordable Care Act reflects and is consistent with 
these principles.
  One principle identified by BCIAA is that an individual with brain 
injury should have access to the full treatment continuum to manage the 
disease that includes early, acute treatment to stabilize the condition 
followed by acute and specialized post-acute brain injury treatment and 
rehabilitation, including inpatient, outpatient, day treatment and home 
health programs, to minimize and/or prevent medical complication, 
recover function and cope with remaining physical or mental 
disabilities, and achieve durable outcomes that maintain an optimal 
level of health, function and independence following brain injury. The 
Patient Protection and Affordable Care Act authorizes the Secretary of 
Health and Human Services to define the details and limits of the 
essential health benefits package but establishes certain general 
categories of benefits that must be covered. The bill specifically 
lists, among other things, hospitalization, outpatient hospital and 
outpatient clinic services, professional services of physicians and 
other health professionals, and prescription drugs. In addition, I am 
pleased that the list includes the following benefits that are of 
particular importance to persons with brain injury:
  Rehabilitative and habilitative services and devices,
  Mental health and substance use disorder services, including 
behavioral treatment, and
  Chronic disease management.
  I believe that for individuals with disabilities such as brain 
injury, rehabilitation and habilitation is equivalent to the provision 
of antibiotics to a person with an infection--both are essential 
medical interventions. The term ``rehabilitative and habilitative 
services'' includes items and services used to restore functional 
capacity, minimize limitations on physical and cognitive functions, and 
maintain or prevent deterioration of functioning as a result of an 
illness, injury, disorder or other health condition. Such services also 
include training of individuals with mental and physical disabilities 
to enhance functional development.
  The term ``rehabilitative and habilitative devices'' includes durable 
medical equipment, prosthetics, orthotics, and related supplies. It is 
my understanding that the Patient Protection and Affordable Care Act 
requires the Secretary of HHS to develop, through regulation, standard 
definitions of many terms, including durable medical equipment for 
purposes of comparing benefit categories from one private health plan 
to another. It is my expectation ``prosthetics, orthotics, and related 
supplies'' will be defined separately from ``durable medical 
equipment'' and the Secretary is not to define durable medical 
equipment for purposes of ``in-home'' use only.
  I defining the list of categories of essential health benefits, I am 
particularly pleased that the bill states that the Secretary shall:
  Ensure that such benefits reflect an appropriate balance among the 
categories so that benefits are not unduly weighted toward any 
category;
  Not make coverage decisions, determine reimbursement rates, establish 
incentive programs, or design benefits in ways that discriminate 
against individuals because of their age, disability, or expected 
length of life;
  Take into account the health care needs of diverse segments of the 
population, including women, children, persons with disabilities, and 
other groups; and
  Ensure that essential benefits not be subject to denial on the basis 
of the individual's present or predicted disability, degree of medical 
dependency, or quality of life.
  Taken together, these are strong protections that will help ensure 
that the essential health benefits package--that must be offered by all 
health plans that participate in the new Health Insurance Exchanges--
will take into account the needs of people with brain injury and other 
disabilities and chronic conditions and not impose value judgments 
about disability and quality of life. This legislative language makes 
clear that Congress understands the subtle discrimination that can 
occur against people with brain injury and other disabilities in the 
area of benefit design.
  A provision in the bill allows insurance companies to sell insurance 
products across State lines. It is my understanding that the new 
federal standards regarding essential benefits are meant to act as a 
floor, not a ceiling, for these essential benefits, giving room for 
plans within states to offer more generous coverage to their 
constituents. Thus, it is also my understanding that all state benefit 
and consumer protection laws will be accorded full force and effect 
when multi-state compacts are organized under one state's laws but sell 
insurance across state lines.
  A second principle identified by BIAA is that an individual with a 
brain injury should have an individualized medical treatment plan that 
documents specific diagnosis-related goals when the person has a 
reasonable expectation of achieving measurable functional improvements 
in a predictable period of time through the provision of treatment of 
sufficient scope, duration and intensity. As described above, I am 
pleased to report that under the bill, payment for items and services 
included in the essential benefits package should be made in accordance 
with generally accepted standards of medical and other appropriate 
clinical or professional practice. In addition, under the bill, a 
qualified health benefits plan may not impose any restriction (other 
than

[[Page 4198]]

cost-sharing) unrelated to clinical appropriateness on the coverage of 
the health items and services included in the essential benefits 
package. Consistent with medical, clinical, and professional practice, 
appropriateness should be determined based on the unique needs of the 
individual with brain injury and treatment should be of sufficient 
scope, duration, and intensity.
  A third principle identified by BIAA is that individuals with brain 
injury should receive treatment in the most appropriate treatment 
setting by accredited programs including acute care hospitals, 
inpatient rehabilitation facilities, residential rehabilitation 
facilities, day treatment programs, outpatient clinics and home health 
agencies as determined in accordance with the choice and aspirations of 
the patient and family in concert with an interdisciplinary team of 
qualified and specialized clinicians. I am pleased that the bill 
includes important patient protections that are designed to permit 
providers to fully discuss treatment options with patients and their 
families and permit the patient to render an informed choice as to 
their course of rehabilitation or other treatment. These patient 
protections are also designed to ensure that the patient receives 
appropriate medical care and that the health care treatment is 
available for the full duration of the patient's medical needs.
  More specifically, the bill restricts the Secretary in a number of 
important ways from creating rules that potentially restrict access to 
certain benefits or settings of care. The bill states that the 
Secretary shall not promulgate any regulation that:
  Creates any unreasonable barriers to the ability of individuals to 
obtain appropriate medical care;
  Impedes timely access to health care services;
  Interferes with communications regarding the full range of treatment 
options between the patient and provider;
  Restricts the ability of health care providers to provide full 
disclosure of all relevant information to patients making health care 
decisions;
  Violates the principles of informed consent and the ethical standards 
of health care professionals; or
  Limits the availability of health care treatment for the full 
duration of the patient's medical needs.
  In addition, the bill specifies that a group health plan and a health 
insurance issuer shall not discriminate with respect to participation 
in the group or individual health insurance plan or coverage against 
any health care provider who is acting within the scope of that 
provider's license or certification under applicable state law. The 
bill also specifies that health plans to be considered ``qualified'' by 
the Secretary must ensure ``a sufficient choice of providers (in a 
manner consistent with applicable network adequacy provisions under 
section 2702(c) of the Public Health Services Act) and provide 
information to enrollees and prospective enrollees on the availability 
of in-network and out-of-network providers'' in order to ensure 
enrollee access to covered benefits, treatments and services under a 
qualified health benefits plan. Thus, rehabilitative and habilitative 
services and chronic disease management services must be available from 
a full continuum of accredited programs and treatment settings at a 
level of intensity that is consistent with the needs of the patient.
  A fourth principle identified by BIAA is that the bill should prevent 
private insurance systems from delaying or denying treatment as a means 
of transferring the burden of brain injury care to taxpayers at 
federal, state and local levels; ensure that both public and private 
health insurance systems meet the health care needs of people with 
brain injury; and avoid using Medicaid and Medicare as the first option 
for coverage of people with brain injury. I am pleased to report that 
the bill includes numerous requirements reforming the health insurance 
marketplace that should prevent private insurance systems from delaying 
or denying treatment for individuals with brain injury. These reforms 
include: prohibiting pre-existing condition exclusions; requiring 
guaranteed issue and renewal; requiring nondiscrimination in health 
benefits or benefit structure in terms of factors such as health 
status, medical condition, medical history, disability or any other 
health status-related factor; limits cost-sharing, and prohibits the 
imposition of lifetime limits or unreasonable annual limits on the 
dollar value of benefits for any individual. I believe that these 
provisions should help prevent private insurance from delaying or 
denying treatment to persons with brain injury.
  The Patient Protection and Affordable Care Act includes provisions 
rewarding quality through market-based incentives, including 
consideration of payment structures that provide increased 
reimbursement or other incentives for, among other things, improving 
health outcomes through the implementation of activities that include 
effective case management, care coordination, and chronic disease 
management. The bill also includes numerous provisions designed to 
encourage the development of new patient care models that address the 
needs of persons requiring comprehensive rehabilitation and chronic 
care management, including models that facilitate the maintenance of 
close relationships between care coordinators, primary care physicians, 
specialist physicians, community-based organizations, and other 
providers of services and suppliers.
  Separate provisions are included in the Patient Protection and 
Affordable Care Act regarding post-acute care (PAC) bundling under 
Medicare. The bill provides for the establishment of a national pilot 
program for integrated care around a hospitalization in order to 
improve coordination, quality, and efficiency of health care services. 
Under the bill, the Secretary will select 1 or more of 8 conditions, 
taking into consideration, among other things, whether a condition is 
high volume and most amenable to bundling. Applications to participate 
in the pilots may be made by ``participating providers'' consisting of 
providers of services and suppliers, including but not limited to 
hospitals.
  BIAA, in a submission to the chair of the Senate Finance Committee 
commented that post-acute payment systems must facilitate, not impede, 
improvements in functional status of individuals with brain injury and 
their ability to return to their homes and communities. BIAA supports a 
deliberative planning process and rigorous pilot testing. The 
deliberative process should determine, among other things, whether PAC 
bundling should exempt diagnoses such as brain injury, which are of low 
predictability and highly complicated; and test innovative payment 
methods that make payments directly to nonhospital-based treatment 
centers, including residential rehabilitation facilities specializing 
in the treatment of brain injury that have earned accreditation by the 
Joint Commission on Accreditation of Healthcare Facilities and/or the 
Commission on Accreditation of Rehabilitation Facilities.
  I agree with the comments presented by BIAA. I am pleased that the 
Patient Protection and Affordable Care Act is consistent with BIAA's 
comments and addresses their concerns. I have some reservations 
regarding the bundling of post-acute care that require the ``bundle'' 
be earmarked to an acute care hospital for patients with complex and 
highly unpredictable diagnosis and health outcomes, as is the case for 
individuals with brain injury and other catastrophic conditions. I 
agree with BIAA that such payment systems may impede, rather than 
facilitate, improvements in functional status and may result in 
premature return to homes and undue levels of preventable disability 
without adequate facilitation of progression through necessary step 
down levels of treatment.
  In closing, I believe the Patient Protection and Affordable Care Act 
addresses the unique health care needs of individuals with brain injury 
by recognizing that brain injury is the start of a lifelong disease 
process requiring access to a full continuum of medically necessary 
treatment, including rehabilitation services and devices and chronic 
disease management, furnished by accredited programs in the most 
appropriate treatment setting as determined in accordance with the 
choices and aspirations of the patient and family in concert with an 
interdisciplinary team of qualified and specialized clinicians.
  Mr. STARK. Mr. Speaker, I, on behalf of myself and Ms. Slaughter, 
rise to speak about the Independent Payment Advisory Board, IPAB, which 
is a new executive branch body created in the Senate-passed health 
reform bill and charged with constraining Medicare spending. The IPAB 
is given unprecedented power to make sweeping changes to the Medicare 
program without going to Congress for approval. I and many of my 
colleagues in the House are concerned about some of the specific 
provisions and procedural changes included in section 3403 of H.R. 
3590.
  Since its inception in 1965, Medicare has guaranteed access to health 
care for 115 million Americans who would otherwise find it nearly 
impossible to obtain affordable health insurance in the private market: 
senior citizens, people with disabilities, and those with end-stage 
renal disease. Medicare is a critical part of this nation's social 
compact, and it is our obligation as elected representatives of our 
constituents to protect and preserve the program now and in the future. 
The health care reform legislation fulfills this responsibility by 
making a number of substantial improvements to Medicare, including 
provisions that improve benefits, extend solvency by at least 9 years 
and winnow out waste, fraud and abuse.

[[Page 4199]]

  As part of the effort to make improvements to the Senate-passed bill, 
key chairmen and Members of the House and Senate, along with the 
administration, were also working on a number of important and 
necessary changes to the IPAB policy. Unfortunately, the Senate 
Parliamentarian indicated that any attempt to improve IPAB in the 
reconciliation bill would be ruled out of order, and could jeopardize 
the status of the entire reconciliation bill.
  Since we were unable to make any changes to the IPAB as part of the 
reconciliation bill, I would like to identify critical improvements 
that need to be made in subsequent legislation. Many of these changes 
had been agreed to by our colleagues in the Senate, as well as the 
administration, and I look forward to working with them to ensure they 
are enacted in the near future.
  While IPAB is designed to help control growing costs in Medicare 
through swift implementation of payment and delivery reforms, the 
actions of the board will be driven by the need to meet targets for 
Medicare cost growth. As we have seen with prior attempts to control 
health care spending, limiting spending to arbitrary and 
unrealistically low growth caps is a recipe for failure. In order for 
IPAB to have any real hope of controlling Medicare cost growth without 
threatening access to care, as is required, the growth targets must be 
rational and realistic. The current spending targets mandated by IPAB 
are neither. They fail to fully take into account the three variables 
that drive health spending growth: price, volume of services, and 
intensity of services. The target only accounts for price growth, and 
does so at an unrealistically low rate. Controlling costs in the health 
care system is important, and I am committed to doing so. In fact, 
Medicare growth has typically been below private sector health care 
cost growth. However, the growth targets established by IPAB need to be 
revised and increased to reflect a more realistic expectation about how 
much growth can be slowed in order to ensure continued access to care 
and a strong program infrastructure in the future.
  The IPAB policy as written by the Senate also tips the balance of 
power too far in favor of the executive branch. In the event that IPAB 
cannot agree on Medicare recommendations required by the targets, the 
Senate bill requires the Health and Human Services Secretary to make 
recommendations instead. Like IPAB's proposal, the Secretary's proposal 
would become law unless Congress passes an alternative. It is one thing 
to give an independent board of health care experts such sweeping power 
to change the Medicare program, but it is quite another to give that 
power to a partisan political figure who reports directly to the 
President. I say this not as a negative comment directed toward our 
current Secretary or President, but a general concern about whether we 
should empower one person with the ability to make such potentially 
sweeping changes to the Nation's signature health program.
  Furthermore, by placing unprecedented procedural barriers to 
congressional consideration of alternatives to the IPAB or secretarial 
proposals, the bill attempts to virtually lock Congress out of the 
process of making changes to Medicare. In the event IPAB or the 
Secretary mandates implementation of draconian cuts to Medicare, 
Congress will encounter procedural barriers to changing those 
recommendations in a meaningful way.
  Thus, in order to maintain a proper balance between Congress and the 
executive branch, all parties had agreed to use a sequestration process 
to meet the mandated savings targets should IPAB fail to make 
recommendations on how to meet those targets. Instead of the decisions 
going to the executive branch, the onus would fall on Congress to 
arrive at thoughtful ways of reducing spending. If Congress failed to 
agree on ways to reduce spending, sequestration would go into effect. 
But it would be my hope and expectation that this would not happen, and 
that Congress would instead be spurred to action by the threat of 
sequestration.
  Another important flaw with IPAB that needs to be addressed is the 
fact that it ignores the broken system used to update Medicare 
physician payment rates. Under current law, the sustainable growth rate 
formula will require physician payment rates to be reduced by more than 
30 percent over the next decade. Yet, the IPAB could decide to make 
additional cuts on top of those already set to take place. The House 
has passed legislation that would make comprehensive permanent reforms 
to the physician payment formula, but that bill has not been taken up 
by the Senate. As such, all parties agreed that physician payment rates 
should be off limits to IPAB until the sustainable growth rate is 
replaced with a permanent, stable way of updating payments to 
physicians.
  I also want to clarify legislative intent with regard to one issue in 
IPAB. Section 1899A(c)(2)(A)(iii) of the Social Security Act, as added 
by Section 3403 of PPACA, states that in the case of IPAB proposals 
submitted prior to December 31, 2018, IPAB shall not include any 
recommendations that would reduce payment rates for providers that 
receive an additional market basket cut on top of the productivity 
adjustment. The rationale for this provision is that these providers 
are already facing extra downward adjustments in their payments and 
thus should not be subject to ``double jeopardy'' by also being subject 
to IPAB recommendations which will further reduce spending. In creating 
this exclusion, it is the intent of Congress to exclude all payment 
reductions applicable to providers captured by this language in all the 
relevant years. Therefore, in the case of inpatient hospitals, the 
provision excludes from IPAB recommendations payment reductions 
applicable to hospitals including payment reductions for indirect 
medical education under 1886(d)(5)(B), graduate medical education under 
1886(h), disproportionate share hospital payments under 1886(d)(5)(F), 
and capital payments, as well as incentives for adoption and 
maintenance of meaningful use of certified electronic health record 
technology under 1886(n). In addition, further clarifications are 
needed to ensure that IPAB is empowered to seek savings or payment 
improvements for all items and services provided to Medicare 
beneficiaries.
  There are smaller, but no less important additional improvements that 
I believe need to be made. Changes made to the Medicare program by IPAB 
are granted broad exemption from judicial review. We should remove this 
exemption to ensure that IPAB is not above the law and its actions can 
be reviewed in a court of law.
  The legislation also prevents IPAB from making changes that would 
increase premiums or ration care, but it is important to include the 
specific protections that are scattered through the Social Security 
Act. Medicare law contains an array of beneficiary protections that are 
designed to ensure that seniors and people with disabilities have 
access to affordable care. The IPAB should not be permitted to make 
changes to these key beneficiary protections.
  Finally, as the legislation is written, IPAB would be required to 
reduce spending above the growth targets resulting from unforeseen and 
unavoidable health events, such as a flu pandemic, hurricane, or act of 
terrorism. Increases in spending from these kinds of catastrophic 
events should be excluded from the overall spending targets.
  Mr. TURNER. Mr. Speaker, I strongly oppose a government takeover of 
our nation's healthcare system. It is irresponsible for Congress to 
approve a vastly unpopular and costly measure at a time of 
unprecedented budget deficits and uncertainty about the future of the 
economy. Despite overwhelming opposition by the American people, the 
Majority in Congress, led by Speaker Pelosi, has resorted to 
manipulating longstanding procedural rules to rush through an overhaul 
of our nation's healthcare system. My constituents understand that any 
bill that requires backroom special deals to pass is fundamentally 
flawed.
  Obtaining quality medical care is a top priority for Ohioans and 
their families. Instead of forcing an unpopular, one-size-fits-all 
approach to healthcare reform, Congress and the White House should 
listen to the American people and return to the drawing board to 
negotiate a real bipartisan agreement in order to achieve true reform.
  Real health care reform does not have to undermine the strengths of 
our current system, nor limit doctor choice or care availability. A 
series of commonsense measures will go a long way toward improving 
health care for all Americans. For example, insurance companies should 
be prohibited from excluding a person for coverage based on pre-
existing conditions.
  Medical research is also essential to bringing health care costs 
down. Private ingenuity is the strength of our current system and 
should be preserved and encouraged. The federal bureaucracy cannot 
stand in the way of such important research.
  When employees change jobs, they should be able to take their health 
insurance with them. Continuity of coverage can be critical for a 
person in the midst of important health-related treatment.
  Our litigation system forces doctors and hospitals to raise operating 
costs. For decades, the cost of medical liability has risen much more 
rapidly than actual medical care. Limiting frivolous lawsuits would 
have a significant effect on containing health care costs and promoting 
accessibility to care.
  Individuals should be allowed to deduct the full cost of their health 
insurance premiums from their federal income taxes. Furthermore,

[[Page 4200]]

we should expand the ability to put tax-free dollars into Health 
Savings Accounts (HSAs) to be used for lifetime medical expenses. These 
measures alone would make health care more affordable for many.
  These are reasonable reforms that don't rely upon the creation of a 
new, massive government health system. Although I oppose this bill, I 
will continue to fight to replace this government takeover of our 
healthcare system, and I remain committed to supporting Southwest 
Ohioans' call for commonsense solutions.
  Mr. CARDOZA. Mr. Speaker, I would like to submit for the Record a 
letter sent to me by the Physician Insurers Association (PIAA) 
expressing their concerns that multiple provisions of H.R. 3590 could 
potentially create new causes of action for medical liability claims 
despite the assurances I received from the committees and others that 
there would be no impact.
  Mr. Speaker, the House-passed H.R. 3962 prevented these causes of 
action from being created by adding Section 261. Section 261 stated 
that the development, recognition, or implementation of any guideline 
or other standard shall not be construed to establish the standard of 
care or the duty of care owed by healthcare providers to their patients 
in any malpractice action or claim.
  Mr. Speaker, for the record, it was the legislative intent of 
Congress to insert Section 261 or similar language in any Conference 
Committee bill to prevent new causes of action. It was not and never 
has been the intent of this legislation to create any new causes of 
action or claims premised on the development of guidelines or other 
standards.

                                                Physician Insurers


                                       Association of America,

                                     Rockville, MD, March 9, 2010.
     Hon. Dennis Cardoza,
     Longworth Building,
     Washington, DC.
       Dear Congressman Cardoza: On behalf of the 60 domestic 
     primary medical professional liability insurance company 
     members of the Physician Insurers Association of America 
     (PIAA), I am writing regarding the healthcare reform 
     legislation passed by the Senate. Specifically, I would like 
     to share our concerns about the legislation creating new 
     causes of action for medical liability claims.
       The PIAA is the only trade association in the nation 
     dedicated solely to the medical professional liability 
     insurance industry. Our members are physician and other 
     healthcare provider owned or operated professional liability 
     insurers which provide indemnification for over 60% of 
     America's doctors, as well as dentists, hospitals and other 
     healthcare providers. Our member insurance companies were 
     formed by state medical, dental and hospital associations 
     over the past 30 years, to include 4 which are domiciled in 
     California. They were formed with the specific goals of 
     lowering insurance costs for providers and helping patients 
     through sound underwriting and patient safety practices. In 
     this regard, we are uniquely qualified to offer our 
     perspective on medical liability issues.
       As approved by the Senate, H.R. 3590 contains at least 14 
     provisions which could create new causes of action for 
     medical liability claims. These include:
       Section 2701 (adult health quality measures).
       Section 2702 (payment adjustments for health care acquired 
     conditions).
       Section 3001 (Hospital Value-Based Purchase Program).
       Section 3002 (improvements to the Physician Quality 
     Reporting Initiative).
       Section 3003 (improvements to the Physician Feedback 
     Program).
       Section 3007 (value based payment modifier under physician 
     fee schedule).
       Section 3008 (payment adjustment for conditions acquired in 
     hospitals).
       Section 3013 (quality measure development).
       Section 3014 (quality measurement).
       Section 3021 (Establishment of Center for Medicare and 
     Medicaid Innovation).
       Section 3025 (hospital readmission reduction program).
       Section 3501 (health care delivery system research, quality 
     improvement).
       Section 4003 (Task Force on Clinical and Preventive 
     Services).
       Section 4301 (research to optimize deliver of public health 
     services).
       Sufficient questions were raised about these sections of 
     H.R. 3590 that a provision was added to the bill 
     commissioning a Government Accountability Office (GAO) study 
     to see if these sections did indeed result in new avenues for 
     medical liability claims to be filed. Quite simply, such a 
     study is unnecessary and possibly harmful. If Congress 
     intends to create multiple new avenues for the filing of 
     medical liability claims, it does not need to commission the 
     study. If, as we have been told, it does not intend to 
     substantially increase medical liability litigation, a study 
     will only needlessly create an opening for such cases to be 
     filed until Congress finds the opportunity to correct the 
     issue.
       Congress should not wait for a study to be conducted--it 
     should clearly state its intent in the legislation to not 
     create new medical liability causes of action which could 
     dramatically increase medical liability insurance premiums 
     and potentially decrease access to healthcare providers in 
     the process. The PIAA recommends the following legislation 
     language to address this issue:
       Sec. XXXX--Construction Regarding Standard of Care
       The development, recognition, or implementation of any 
     guideline or other standard under any provision of this Act 
     shall not be construed to establish the standard of care or 
     duty of care owed by healthcare providers to their patients 
     in any medical malpractice action or claim (as defined in 
     section 431(7) of the Health Care Quality Improvement Act of 
     1986 (42 U.S.C.10 11151(7)).
       From the very beginning of the healthcare reform debate, 
     there has been broad consensus that medical liability reform 
     was a necessary component in making our healthcare system 
     more efficient and effective. While the exact nature of that 
     reform has been the source of some disagreement, no one has 
     been suggesting that our medical system will be improved by 
     having new opportunities for even more medical liability 
     claims to be filed. Congress should ensure such opportunities 
     are not created by healthcare reform legislation.
       Thank you for your time and consideration of this 
     critically important issue. Should you have any questions 
     about these proposals, or need additional information, please 
     do not hesitate to contact me. We look forward to working 
     with you on this most important issue.
           Sincerely,
                                                Lawrence E. Smarr,
                                                        President.

  Ms. SCHWARTZ. Mr. Speaker, I, on behalf of myself and Mr. Neal, rise 
to speak about the Independent Payment Advisory Board (IPAB), which is 
a new executive branch entity created in the Senate passed health 
reform bill, H.R. 3590, the Patient Protection and Affordable Care Act.
  In particular I want to clarify legislative intent with regard to one 
issue in IPAB. Section 1899A(c)(2)(A)(iii) of the Social Security Act, 
as added by Section 3403 of PPACA, states that in the case of IPAB 
proposals submitted prior to December 31, 2018, IPAB shall not include 
any recommendations that would reduce payment rates for providers that 
receive an additional market basket cut on top of the productivity 
adjustment. The rationale for this provision is that these providers 
are already facing extra downward adjustments in their payments and 
thus should not be subject to ``double jeopardy'' by also being subject 
to IPAB recommendations which will further reduce spending.
  In creating this exclusion, it is the intent of Congress to exclude 
all payment reductions applicable to providers captured by this 
language in all the relevant years. Therefore, in the case of inpatient 
hospitals, the provision excludes from IPAB recommendations payment 
reductions applicable to hospitals including payment reductions for 
indirect medical education under 1886(d)(5)(B), graduate medical 
education under 1886(h), disproportionate share hospital payments under 
1886(d)(5)(F), and capital payments, as well as incentives for adoption 
and maintenance of meaningful use of certified electronic health record 
technology under 1886(n).
  In addition, further clarifications are needed to ensure that IPAB is 
empowered to recommend payment improvements for all items and services 
provided to Medicare beneficiaries.
  Mr. BONNER. Mr. Speaker, I rise in strong opposition to H.R. 3590, 
The Patient Protection and Affordable Care Act, and H.R. 4872, The 
Health Care and Education Affordability Reconciliation Act of 2010. 
These severely misguided bills authorize $1.2 trillion in new mandatory 
spending over the next decade, impose costly unfunded mandates on 
States, increase taxes on small businesses and families by more than 
$500 billion over ten years, and provide a clear path for federal 
funding of abortions.
  Both President Obama and Speaker Pelosi have talked about the 
``historic'' nature of their health care legislation. While they claim 
to be acting upon the unrealized goals of a century of past Presidents 
and Congresses to expand health care access to all Americans, the real 
history that's being made by the passage of the legislation is less 
inspiring. Rather than seeking a national consensus to forge a truly 
historic, and badly needed reform of American health care, the 
President and the Speaker instead cynically crafted alone a one-sided, 
purely partisan bill that ignores the desires of the majority of the 
people.
  Unlike the Social Security and Medicare Acts which enjoyed strong 
bipartisan support in their day, the President and the Speaker's health 
care legislation, which will impact nearly one-sixth of the economy, 
did not see one single Republican vote in support of their effort.

[[Page 4201]]

Furthermore, 34 members of their own party joined Republicans in 
opposing this blatant power grab, dressed up as health care reform.
  The reason for this lopsided vote is clear. The Democrat health care 
plan facilitates a backdoor takeover of American health care. The 
Federal Government would force small businesses and even individuals to 
buy health coverage or face stiff penalties. This mandate may well be 
unconstitutional and, in many states, including my State of Alabama, 
there are already attempts to challenge this in court.
  This $1.2 trillion health care scheme will increase federal deficits 
by $59 billion over the next ten years, while inflicting a painful 
combination of Medicare cuts and tax increases, affecting millions of 
seniors, families and small businesses.
  Ironically, the elderly--the most vulnerable to high medical costs--
will suffer the loss of $200 billion from the popular Medicare 
Advantage program, upon which over 170,000 Alabama seniors rely. In 
all, a total of $500 billion will be taken from Medicare to pay for the 
broad health care expansion.
  But that's not all. This bill will also, for the first time, levy 
Medicare taxes on investment income. It imposes a new tax of 3.8 
percent on unearned income.
  Small businesses would also be forced to provide a government-
approved level of coverage or face a $2,000 penalty per employee. 
Businesses already providing coverage would face the same penalties if 
the government deems the coverage ``unaffordable.''
  What's more, individuals would also have to buy government-approved 
insurance--whether they want it or not--or face fines. The IRS will 
become the health care enforcement agency, hiring up to 16,000 new 
workers to ensure that everyone buys federally approved coverage.
  The Democrat health care bill will also place an unfunded mandate on 
States to expand Medicaid rolls. In my State, it will move an 
additional 400,000 people into an already cash-strapped Alabama 
Medicaid program. Alabama will have to come up with an additional $61 
million annually to sustain this mandatory expansion of Medicaid, which 
will cost State and Federal taxpayers a total of nearly $1.1 billion a 
year. As Governor Bob Riley recently said, ``I am deeply concerned that 
sustaining this level of coverage would translate into a substantial 
tax increase on the people of Alabama.''
  Equally troubling is this health care bill's green light for the 
federal funding of abortions. Despite the President's Executive Order 
barring the use of any Federal funds for abortion, there is no 
permanent prohibition over using Federal funds to pay for abortions. 
Whatever deal Rep. Bart Stupak and his group think they may have struck 
with the President, it does not carry the force of law. Executive 
orders are signed by the President and they can be revoked by the 
President--and frequently, they are.
  Mr. Speaker, Republicans have been shut out of the President's and 
your health care bill from the beginning. We offered to sit down and 
start from scratch to write a bill the American people could actually 
support, including the ability to buy insurance across State lines, 
give small businesses the power to pool coverage, and address liability 
lawsuit abuse. The Congressional Budget Office said the Republican 
health care plan would increase access to care, lower premiums by up to 
ten percent and reduce the Federal deficit by $68 billion over ten 
years. Sadly, this kind of real reform was all but ignored by the 
administration and the Congress.
  This is truly a sad day for this House and for our country. Americans 
wanted and deserve so much more than a cynical push for bigger 
government. I am committed to supporting efforts to fix this badly 
flawed legislation and replace it with true health care reform that 
Americans can support.
  Mr. ORTIZ. Mr. Speaker, I rise today in support H.R. 4872, the Health 
Care and Education Affordability Reconciliation Act of 2010 and H.R. 
3590, the Patient Protection and Affordable Act, which promise to bring 
economic prosperity for the betterment of this country and our people.
  Tonight, we vote to expand health care to 32 million Americans, 
including more than 150,000 of my constituents who do not currently 
have any type of health insurance.
  I must remind my friends on both sides of the aisle that this is not 
the first time we take up a tough vote.
  Nobody said that this would be easy. These past days days remind me 
of a critical vote I took in 1993. The atmosphere and rhetoric was much 
the same as today. In 1993, we were told voting in favor of President 
Clinton's budget deficit reduction would destroy our country and no 
member would survive re-election if they voted in favor.
  Despite the negative rhetoric, I carefully examined the proposal and 
voted in favor of the legislation. This was a responsible vote. We 
ultimately benefited by balancing the deficit and creating one of the 
largest debt reductions in the history of our great country. Fiscal 
responsibility led us to more than $400 billion in deficit reduction, 
without destroying our country and providing us a prosperous economy 
with global competitiveness.
  Today, I am faced with another pressing historic vote just as I was 
seventeen years ago.
  Growing up in south Texas and working as a migrant worker without 
health insurance, I understand this issue first-hand. I remember what 
that was like and can empathize with the uninsured and underinsured. I 
remember having asthma, a pre-existing condition, which prohibited me 
from obtaining health care insurance before entering military service.
  More than 45,000 annual deaths occur due to lack of insurance and 
health services. Therefore, I support legislation that reduces the 
number of uninsured people by 32 million and presents a net reduction 
in the deficit of $138 billion over 10 years with a total net reduction 
of $1.3 trillion over the next 20 years. That is a responsible vote.
  I support increasing competition and offering additional affordable 
insurance options to consumers. This legislation will improve coverage 
for 296,000 residents with health insurance and extend coverage to 
158,000 uninsured residents in the 27th District of Texas. Small 
businesses will be able to pool together to obtain lower insurance 
premiums, a benefit that has only been available to large employers. 
Small businesses will be eligible for tax credits to help provide 
employer-based insurance to ensure a healthy competitive workforce.
  After much evaluation, this legislation will benefit the 27th 
District of Texas and I will support the measure when brought to the 
House floor.
  Mr. WAXMAN. Mr. Speaker, regarding spiritual care: The purpose of 
health care reform has been to ensure that all Americans are covered by 
affordable, quality insurance. Some of my colleagues have raised 
concerns about how this impacts Christian Scientists who use certain 
primary care services that are currently eligible for a medical care 
tax deduction.
  Nothing in this health care reform legislation prevents insurance 
companies from covering care that is currently recognized by the 
Internal Revenue Service as eligible for a medical care tax deduction 
through health insurance plans in the Exchanges; nothing in the 
legislation is intended to have such a prohibition. Nothing in this 
legislation is intended to minimize or reduce existing provisions in 
the law that recognizes spiritual care.
  Individual responsibility: The individual responsibility requirement 
requires individuals to pay a tax on their individual tax filings or 
provide information documenting they fulfill the requirements for 
having essential minimum coverage over the past year. Congress makes 
the following findings to support this requirement:
  The individual responsibility requirement provided for in the Patient 
Protection and Affordable Care Act, and amended by Section 1002 of the 
Health Care and Education Reconciliation Act, requires individuals 
either to purchase a minimum level of insurance coverage or to make a 
payment on one's tax return to help cover the cost of uncompensated 
care. This requirement is commercial and economic in nature and 
substantially affects interstate commerce in many ways, including as a 
result of the following aggregate effects:
  (1) The requirement regulates activity that is commercial and 
economic in nature, involving the distribution and consumption of 
health care services throughout the national economy, and in particular 
economic and financial decisions about how and when health care is paid 
for and when health insurance is purchased. Some individuals currently 
make an economic and financial decision to forego health insurance 
coverage and self-insure, paying for charges for services directly to 
the provider and relying on uncompensated care. The decision by 
individuals not to purchase health insurance has many substantial 
effects on the national economy, the national marketplace for health 
insurance, and interstate commerce. In general, individuals who fail to 
purchase health insurance have a diminished capacity to purchase health 
care services, and increase overall health care costs. When such 
individuals inevitably seek medical care, the costs of that care must 
often be paid for by providers, insured individuals and businesses 
through higher premiums, or Federal, State, and local governments. The 
requirement encourages prepayment for services, and affects an 
individual's decision whether or not to purchase health insurance by 
imposing penalties on individuals who remain uninsured. Congressional 
Budget Office, Key Issues in Analyzing Major Health Insurance 
Proposals, December 2008.

[[Page 4202]]

  (2) The uninsured receive about $86,000,000,000 in health care, of 
which about $56,000,000,000 is uncompensated. Private spending on 
uncompensated care is $14,500,000,000, and includes profits forgone by 
physicians and hospitals. Government spending on uncompensated care is 
$42,900,000,000, and is financed by taxpayers at both the State and 
Federal levels. Jack Hadley et al., Covering the Uninsured in 2008: 
Current Costs, Sources of Payment, and Incremental Costs, Health 
Affairs, August 25, 2008.
  (3) Health care received by the uninsured is more costly. The 
uninsured are more likely to be hospitalized for preventable 
conditions. Jack Hadley, Economic Consequences of Being Uninsured: 
Uncompensated Care, Inefficient Medical Care Spending, and Foregone 
Earnings, Testimony before the Senate Subcommittee on Labor, Health and 
Human Services, Education, and Related Agencies, May 14, 2003. 
Hospitals provide uncompensated care of $35,000,000,000, representing 
on average 5 percent of hospital revenues. Health Affairs, August 25, 
2008.
  (4) Those who have private health insurance also pay for 
uncompensated care. Medical providers try to recoup the cost from 
private insurers, which increases family premiums by an average of over 
$1,000 a year. Families USA, Hidden Health Tax: Americans Pay a 
Premium, May 2009.
  (5) The decision to self-insure increases financial risks to 
households throughout the United States. Sixty-two percent of all 
personal bankruptcies are caused by illness or medical bills, and a 
significant portion of medically bankrupted families lacked health 
insurance or experienced a recent lapse in coverage. David U. 
Himmelstein et al., American Journal of Medicine, Medical Bankruptcy in 
the United States, 2007: Results of a National Study, 2009.
  (6) The national economy loses up to $207,000,000,000 a year because 
of the poorer health and shorter lifespan of the uninsured. Elizabeth 
Carpenter and Sarah Axeen, The Cost of Doing Nothing, New America 
Foundation, November 2008.
  (7) A large share of the uninsured are offered insurance at low or 
zero premiums, but choose to forego coverage. New America Foundation, 
December 6, 2007. According to one estimate, the absence of a 
requirement from health reform would leave 50 percent of the uninsured 
without coverage. Linda J. Blumberg and John Holahan, Do Individual 
Mandates Matter?, The Urban Institute, January 2008. While generous 
subsidies alone would not achieve universal coverage, the requirement 
further expands coverage. Congressional Budget Office, December 2008. 
The requirement improves budgetary efficiency by significantly lowering 
the federal cost per newly insured. Jonathan Gruber, Covering the 
Uninsured in the U.S., National Bureau of Economic Research, January 
2008. In Massachusetts, where a similar requirement has been in effect 
since 2007, the share of uninsured declined to 2.7 percent in 2009. 
Massachusetts Division of Healthcare Finance and Policy.
  (8) By regulating the decision to self-insure, and expanding 
coverage, the requirement addresses the problem of free riders who rely 
on more costly uncompensated care, including access to emergency care 
required by federal law to be provided even to the uninsured, shifting 
costs to medical providers, taxpayers, and the privately insured. It 
will also reduce the cost to the national economy of the lower 
productivity of the uninsured.
  The preceding 8 points cite numerous studies and papers which 
illustrate the extensive evidence that the Patient Protection and 
Affordable Care Act, as amended by Section 1002 of the Health Care and 
Education Reconciliation Act, substantially affects interstate 
commerce. These citations are included in their written entirety for 
the record.
  The SPEAKER pro tempore. Under the rule, all time for debate has 
expired.
  Mr. SPRATT. Mr. Speaker, pursuant to House Resolution 1203, I call up 
the bill (H.R. 3590) to amend the Internal Revenue Code of 1986 to 
modify the first-time homebuyers credit in the case of members of the 
Armed Forces and certain other Federal employees, and for other 
purposes, with the Senate amendments thereto, and I have a motion at 
the desk.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore. The Clerk will designate the Senate 
amendments.
  The text of the Senate amendments is as follows:

       Senate amendments:
       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Patient 
     Protection and Affordable Care Act''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

       TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

  Subtitle A--Immediate Improvements in Health Care Coverage for All 
                               Americans

Sec. 1001. Amendments to the Public Health Service Act.

             ``PART A--Individual and Group Market Reforms

                    ``subpart ii--improving coverage

``Sec. 2711. No lifetime or annual limits.
``Sec. 2712. Prohibition on rescissions.
``Sec. 2713. Coverage of preventive health services.
``Sec. 2714. Extension of dependent coverage.
``Sec. 2715. Development and utilization of uniform explanation of 
              coverage documents and standardized definitions.
``Sec. 2716. Prohibition of discrimination based on salary.
``Sec. 2717. Ensuring the quality of care.
``Sec. 2718. Bringing down the cost of health care coverage.
``Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.

     Subtitle B--Immediate Actions to Preserve and Expand Coverage

Sec. 1101. Immediate access to insurance for uninsured individuals with 
              a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify 
              affordable coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.

    Subtitle C--Quality Health Insurance Coverage for All Americans

                PART I--Health Insurance Market Reforms

Sec. 1201. Amendment to the Public Health Service Act.

                      ``subpart i--general reform

``Sec. 2704. Prohibition of preexisting condition exclusions or other 
              discrimination based on health status.
``Sec. 2701. Fair health insurance premiums.
``Sec. 2702. Guaranteed availability of coverage.
``Sec. 2703. Guaranteed renewability of coverage.
``Sec. 2705. Prohibiting discrimination against individual participants 
              and beneficiaries based on health status.
``Sec. 2706. Non-discrimination in health care.
``Sec. 2707. Comprehensive health insurance coverage.
``Sec. 2708. Prohibition on excessive waiting periods.

                       PART II--Other Provisions

Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance 
              issuers and group health plans.
Sec. 1253. Effective dates.

        Subtitle D--Available Coverage Choices for All Americans

            PART I--Establishment of Qualified Health Plans

Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.

  PART II--Consumer Choices and Insurance Competition Through Health 
                           Benefit Exchanges

Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.

           PART III--State Flexibility Relating to Exchanges

Sec. 1321. State flexibility in operation and enforcement of Exchanges 
              and related requirements.
Sec. 1322. Federal program to assist establishment and operation of 
              nonprofit, member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.

      PART IV--State Flexibility to Establish Alternative Programs

Sec. 1331. State flexibility to establish basic health programs for 
              low-income individuals not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one 
              State.

                PART V--Reinsurance and Risk Adjustment

Sec. 1341. Transitional reinsurance program for individual and small 
              group markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and 
              small group markets.
Sec. 1343. Risk adjustment.

[[Page 4203]]

       Subtitle E--Affordable Coverage Choices for All Americans

        PART I--Premium Tax Credits and Cost-sharing Reductions

       subpart a--premium tax credits and cost-sharing reductions

Sec. 1401. Refundable tax credit providing premium assistance for 
              coverage under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified 
              health plans.

                 subpart b--eligibility determinations

Sec. 1411. Procedures for determining eligibility for Exchange 
              participation, premium tax credits and reduced cost-
              sharing, and individual responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and 
              cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an 
              exchange and State Medicaid, CHIP, and health subsidy 
              programs.
Sec. 1414. Disclosures to carry out eligibility requirements for 
              certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments 
              disregarded for Federal and Federally-assisted programs.

                   PART II--Small Business Tax Credit

Sec. 1421. Credit for employee health insurance expenses of small 
              businesses.

           Subtitle F--Shared Responsibility for Health Care

                   PART I--Individual Responsibility

Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.

                   PART II--Employer Responsibilities

Sec. 1511. Automatic enrollment for employees of large employers.
Sec. 1512. Employer requirement to inform employees of coverage 
              options.
Sec. 1513. Shared responsibility for employers.
Sec. 1514. Reporting of employer health insurance coverage.
Sec. 1515. Offering of Exchange-participating qualified health plans 
              through cafeteria plans.

                  Subtitle G--Miscellaneous Provisions

Sec. 1551. Definitions.
Sec. 1552. Transparency in government.
Sec. 1553. Prohibition against discrimination on assisted suicide.
Sec. 1554. Access to therapies.
Sec. 1555. Freedom not to participate in Federal health insurance 
              programs.
Sec. 1556. Equity for certain eligible survivors.
Sec. 1557. Nondiscrimination.
Sec. 1558. Protections for employees.
Sec. 1559. Oversight.
Sec. 1560. Rules of construction.
Sec. 1561. Health information technology enrollment standards and 
              protocols.
Sec. 1562. Conforming amendments.
Sec. 1563. Sense of the Senate promoting fiscal responsibility.

                   TITLE II--ROLE OF PUBLIC PROGRAMS

                Subtitle A--Improved Access to Medicaid

Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified 
              gross income.
Sec. 2003. Requirement to offer premium assistance for employer-
              sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
Sec. 2006. Special adjustment to FMAP determination for certain States 
              recovering from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.

   Subtitle B--Enhanced Support for the Children's Health Insurance 
                                Program

Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.

        Subtitle C--Medicaid and CHIP Enrollment Simplification

Sec. 2201. Enrollment Simplification and coordination with State Health 
              Insurance Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility 
              determinations for all Medicaid eligible populations.

             Subtitle D--Improvements to Medicaid Services

Sec. 2301. Coverage for freestanding birth center services.
Sec. 2302. Concurrent care for children.
Sec. 2303. State eligibility option for family planning services.
Sec. 2304. Clarification of definition of medical assistance.

 Subtitle E--New Options for States to Provide Long-Term Services and 
                                Supports

Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based 
              services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based 
              services against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource 
              Centers.
Sec. 2406. Sense of the Senate regarding long-term care.

            Subtitle F--Medicaid Prescription Drug Coverage

Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.

  Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments

Sec. 2551. Disproportionate share hospital payments.

   Subtitle H--Improved Coordination for Dual Eligible Beneficiaries

Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual 
              eligible beneficiaries.

    Subtitle I--Improving the Quality of Medicaid for Patients and 
                               Providers

Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with 
              chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a 
              hospitalization.
Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration 
              Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.

 Subtitle J--Improvements to the Medicaid and CHIP Payment and Access 
                          Commission (MACPAC)

Sec. 2801. MACPAC assessment of policies affecting all Medicaid 
              beneficiaries.

    Subtitle K--Protections for American Indians and Alaska Natives

Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare 
              part B services furnished by certain indian hospitals and 
              clinics.

             Subtitle L--Maternal and Child Health Services

Sec. 2951. Maternal, infant, and early childhood home visiting 
              programs.
Sec. 2952. Support, education, and research for postpartum depression.
Sec. 2953. Personal responsibility education.
Sec. 2954. Restoration of funding for abstinence education.
Sec. 2955. Inclusion of information about the importance of having a 
              health care power of attorney in transition planning for 
              children aging out of foster care and independent living 
              programs.

     TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE

        Subtitle A--Transforming the Health Care Delivery System

 PART I--Linking Payment to Quality Outcomes Under the Medicare Program

Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient 
              rehabilitation hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled 
              nursing facilities and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee 
              schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.

       PART II--National Strategy to Improve Health Care Quality

Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measurement.
Sec. 3015. Data collection; public reporting.

      PART III--Encouraging Development of New Patient Care Models

Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation 
              within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.

       Subtitle B--Improving Medicare for Patients and Providers

    PART I--Ensuring Beneficiary Access to Physician Care and Other 
                                Services

Sec. 3101. Increase in the physician payment update.

[[Page 4204]]

Sec. 3102. Extension of the work geographic index floor and revisions 
              to the practice expense geographic adjustment under the 
              Medicare physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain 
              physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care 
              hospital services and of moratorium on the establishment 
              of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital 
              extended care services.
Sec. 3109. Exemption of certain pharmacies from accreditation 
              requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE 
              beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.

                       PART II--Rural Protections

Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain 
              clinical diagnostic laboratory tests furnished to 
              hospital patients in certain rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration 
              Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital 
              payment adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community 
              health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health 
              care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital 
              services.
Sec. 3129. Extension of and revisions to Medicare rural hospital 
              flexibility program.

                  PART III--Improving Payment Accuracy

Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital 
              (DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced 
              imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the 
              calculation of the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Sec. 3143. Protecting home health benefits.

               Subtitle C--Provisions Relating to Part C

Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment 
              transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs 
              individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.

 Subtitle D--Medicare Part D Improvements for Prescription Drug Plans 
                            and MA-PD Plans

Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income 
              benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals 
              under prescription drug plans and MA-PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility 
              for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals 
              reassigned to prescription drug plans and MA-PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans 
              and MA-PD plans with respect to certain categories or 
              classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income 
              beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible 
              individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription 
              drugs in long-term care facilities under prescription 
              drug plans and MA-PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan 
              complaint system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug 
              plans and MA-PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs 
              and Indian Health Service in providing prescription drugs 
              toward the annual out-of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.

              Subtitle E--Ensuring Medicare Sustainability

Sec. 3401. Revision of certain market basket updates and incorporation 
              of productivity improvements into market basket updates 
              that do not already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.

              Subtitle F--Health Care Quality Improvements

Sec. 3501. Health care delivery system research; Quality improvement 
              technical assistance.
Sec. 3502. Establishing community health teams to support the patient-
              centered medical home.
Sec. 3503. Medication management services in treatment of chronic 
              disease.
Sec. 3504. Design and implementation of regionalized systems for 
              emergency care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk 
              information.
Sec. 3508. Demonstration program to integrate quality improvement and 
              patient safety training into clinical education of health 
              professionals.
Sec. 3509. Improving women's health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.

   Subtitle G--Protecting and Improving Guaranteed Medicare Benefits

Sec. 3601. Protecting and improving guaranteed Medicare benefits.
Sec. 3602. No cuts in guaranteed benefits.

  TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH

  Subtitle A--Modernizing Disease Prevention and Public Health Systems

Sec. 4001. National Prevention, Health Promotion and Public Health 
              Council.
Sec. 4002. Prevention and Public Health Fund.
Sec. 4003. Clinical and community preventive services.
Sec. 4004. Education and outreach campaign regarding preventive 
              benefits.

     Subtitle B--Increasing Access to Clinical Preventive Services

Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a 
              personalized prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults 
              in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for 
              pregnant women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.

               Subtitle C--Creating Healthier Communities

Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based 
              prevention and wellness programs for Medicare 
              beneficiaries.
Sec. 4203. Removing barriers and improving access to wellness for 
              individuals with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain 
              restaurants.
Sec. 4206. Demonstration project concerning individualized wellness 
              plan.
Sec. 4207. Reasonable break time for nursing mothers.

    Subtitle D--Support for Prevention and Public Health Innovation

Sec. 4301. Research on optimizing the delivery of public health 
              services.
Sec. 4302. Understanding health disparities: data collection and 
              analysis.

[[Page 4205]]

Sec. 4303. CDC and employer-based wellness programs.
Sec. 4304. Epidemiology-Laboratory Capacity Grants.
Sec. 4305. Advancing research and treatment for pain care management.
Sec. 4306. Funding for Childhood Obesity Demonstration Project.

                  Subtitle E--Miscellaneous Provisions

Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.

                     TITLE V--HEALTH CARE WORKFORCE

                  Subtitle A--Purpose and Definitions

Sec. 5001. Purpose.
Sec. 5002. Definitions.

          Subtitle B--Innovations in the Health Care Workforce

Sec. 5101. National health care workforce commission.
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.

     Subtitle C--Increasing the Supply of the Health Care Workforce

Sec. 5201. Federally supported student loan funds.
Sec. 5202. Nursing student loan program.
Sec. 5203. Health care workforce loan repayment programs.
Sec. 5204. Public health workforce recruitment and retention programs.
Sec. 5205. Allied health workforce recruitment and retention programs.
Sec. 5206. Grants for State and local programs.
Sec. 5207. Funding for National Health Service Corps.
Sec. 5208. Nurse-managed health clinics.
Sec. 5209. Elimination of cap on commissioned corps.
Sec. 5210. Establishing a Ready Reserve Corps.

   Subtitle D--Enhancing Health Care Workforce Education and Training

Sec. 5301. Training in family medicine, general internal medicine, 
              general pediatrics, and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration 
              project.
Sec. 5305. Geriatric education and training; career awards; 
              comprehensive geriatric education.
Sec. 5306. Mental and behavioral health education and training grants.
Sec. 5307. Cultural competency, prevention, and public health and 
              individuals with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of 
              title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.

       Subtitle E--Supporting the Existing Health Care Workforce

Sec. 5401. Centers of excellence.
Sec. 5402. Health care professionals training for diversity.
Sec. 5403. Interdisciplinary, community-based linkages.
Sec. 5404. Workforce diversity grants.
Sec. 5405. Primary care extension program.

Subtitle F--Strengthening Primary Care and Other Workforce Improvements

Sec. 5501. Expanding access to primary care services and general 
              surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in nonprovider settings.
Sec. 5505. Rules for counting resident time for didactic and scholarly 
              activities and other activities.
Sec. 5506. Preservation of resident cap positions from closed 
              hospitals.
Sec. 5507. Demonstration projects To address health professions 
              workforce needs; extension of family-to-family health 
              information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.

          Subtitle G--Improving Access to Health Care Services

Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and 
              criteria for designating medically underserved 
              populations and health professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services 
              for Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based 
              mental health settings.
Sec. 5605. Key National indicators.

                     Subtitle H--General Provisions

Sec. 5701. Reports.

              TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY

         Subtitle A--Physician Ownership and Other Transparency

Sec. 6001. Limitation on Medicare exception to the prohibition on 
              certain physician referrals for hospitals.
Sec. 6002. Transparency reports and reporting of physician ownership or 
              investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services 
              exception to the prohibition on physician self-referral 
              for certain imaging services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.

         Subtitle B--Nursing Home Transparency and Improvement

             PART I--Improving Transparency of Information

Sec. 6101. Required disclosure of ownership and additional disclosable 
              parties information.
Sec. 6102. Accountability requirements for skilled nursing facilities 
              and nursing facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.

                     PART II--Targeting Enforcement

Sec. 6111. Civil money penalties.
Sec. 6112. National independent monitor demonstration project.
Sec. 6113. Notification of facility closure.
Sec. 6114. National demonstration projects on culture change and use of 
              information technology in nursing homes.

                   PART III--Improving Staff Training

Sec. 6121. Dementia and abuse prevention training.

Subtitle C--Nationwide Program for National and State Background Checks 
  on Direct Patient Access Employees of Long-term Care Facilities and 
                               Providers

Sec. 6201. Nationwide program for National and State background checks 
              on direct patient access employees of long-term care 
              facilities and providers.

             Subtitle D--Patient-Centered Outcomes Research

Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness 
              research.

 Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions

Sec. 6401. Provider screening and other enrollment requirements under 
              Medicare, Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity 
              and Protection Data Bank and the National Practitioner 
              Data Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to 
              not more than 12 months.
Sec. 6405. Physicians who order items or services required to be 
              Medicare enrolled physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on 
              referrals to programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before 
              physicians may certify eligibility for home health 
              services or durable medical equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment, 
              prosthetics, orthotics, and supplies competitive 
              acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.

      Subtitle F--Additional Medicaid Program Integrity Provisions

Sec. 6501. Termination of provider participation under Medicaid if 
              terminated under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain 
              ownership, control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees 
              required to register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under 
              MMIS to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located 
              outside of the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.

          Subtitle G--Additional Program Integrity Provisions

Sec. 6601. Prohibition on false statements and representations.

[[Page 4206]]

Sec. 6602. Clarifying definition.
Sec. 6603. Development of model uniform report form.
Sec. 6604. Applicability of State law to combat fraud and abuse.
Sec. 6605. Enabling the Department of Labor to issue administrative 
              summary cease and desist orders and summary seizures 
              orders against plans that are in financially hazardous 
              condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential 
              communications.

                     Subtitle H--Elder Justice Act

Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.

     Subtitle I--Sense of the Senate Regarding Medical Malpractice

Sec. 6801. Sense of the Senate regarding medical malpractice.

      TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

         Subtitle A--Biologics Price Competition and Innovation

Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
Sec. 7003. Savings.

  Subtitle B--More Affordable Medicines for Children and Underserved 
                              Communities

Sec. 7101. Expanded participation in 340B program.
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B 
              program.

                         TITLE VIII--CLASS ACT

Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for 
              purchasing community living assistance services and 
              support.

                      TITLE IX--REVENUE PROVISIONS

                 Subtitle A--Revenue Offset Provisions

Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on 
              W-2.
Sec. 9003. Distributions for medicine qualified only if for prescribed 
              drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and 
              Archer MSAs not used for qualified medical expenses.
Sec. 9005. Limitation on health flexible spending arrangements under 
              cafeteria plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription 
              pharmaceutical manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and 
              importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare 
              Part D subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health 
              insurance providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health 
              organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.

                      Subtitle B--Other Provisions

Sec. 9021. Exclusion of health benefits provided by Indian tribal 
              governments.
Sec. 9022. Establishment of simple cafeteria plans for small 
              businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.

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

               Subtitle A--Provisions Relating to Title I

Sec. 10101. Amendments to subtitle A.
Sec. 10102. Amendments to subtitle B.
Sec. 10103. Amendments to subtitle C.
Sec. 10104. Amendments to subtitle D.
Sec. 10105. Amendments to subtitle E.
Sec. 10106. Amendments to subtitle F.
Sec. 10107. Amendments to subtitle G.
Sec. 10108. Free choice vouchers.
Sec. 10109. Development of standards for financial and administrative 
              transactions.

              Subtitle B--Provisions Relating to Title II

                       PART I--Medicaid and CHIP

Sec. 10201. Amendments to the Social Security Act and title II of this 
              Act.
Sec. 10202. Incentives for States to offer home and community-based 
              services as a long-term care alternative to nursing 
              homes.
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and 
              other CHIP-related provisions.

      PART II--Support for Pregnant and Parenting Teens and Women

Sec. 10211. Definitions.
Sec. 10212. Establishment of pregnancy assistance fund.
Sec. 10213. Permissible uses of Fund.
Sec. 10214. Appropriations.

                PART III--Indian Health Care Improvement

Sec. 10221. Indian health care improvement.

              Subtitle C--Provisions Relating to Title III

Sec. 10301. Plans for a Value-Based purchasing program for ambulatory 
              surgical centers.
Sec. 10302. Revision to national strategy for quality improvement in 
              health care.
Sec. 10303. Development of outcome measures.
Sec. 10304. Selection of efficiency measures.
Sec. 10305. Data collection; public reporting.
Sec. 10306. Improvements under the Center for Medicare and Medicaid 
              Innovation.
Sec. 10307. Improvements to the Medicare shared savings program.
Sec. 10308. Revisions to national pilot program on payment bundling.
Sec. 10309. Revisions to hospital readmissions reduction program.
Sec. 10310. Repeal of physician payment update.
Sec. 10311. Revisions to extension of ambulance add-ons.
Sec. 10312. Certain payment rules for long-term care hospital services 
              and moratorium on the establishment of certain hospitals 
              and facilities.
Sec. 10313. Revisions to the extension for the rural community hospital 
              demonstration program.
Sec. 10314. Adjustment to low-volume hospital provision.
Sec. 10315. Revisions to home health care provisions.
Sec. 10316. Medicare DSH.
Sec. 10317. Revisions to extension of section 508 hospital provisions.
Sec. 10318. Revisions to transitional extra benefits under Medicare 
              Advantage.
Sec. 10319. Revisions to market basket adjustments.
Sec. 10320. Expansion of the scope of, and additional improvements to, 
              the Independent Medicare Advisory Board.
Sec. 10321. Revision to community health teams.
Sec. 10322. Quality reporting for psychiatric hospitals.
Sec. 10323. Medicare coverage for individuals exposed to environmental 
              health hazards.
Sec. 10324. Protections for frontier States.
Sec. 10325. Revision to skilled nursing facility prospective payment 
              system.
Sec. 10326. Pilot testing pay-for-performance programs for certain 
              Medicare providers.
Sec. 10327. Improvements to the physician quality reporting system.
Sec. 10328. Improvement in part D medication therapy management (MTM) 
              programs.
Sec. 10329. Developing methodology to assess health plan value.
Sec. 10330. Modernizing computer and data systems of the Centers for 
              Medicare & Medicaid services to support improvements in 
              care delivery.
Sec. 10331. Public reporting of performance information.
Sec. 10332. Availability of medicare data for performance measurement.
Sec. 10333. Community-based collaborative care networks.
Sec. 10334. Minority health.
Sec. 10335. Technical correction to the hospital value-based purchasing 
              program.
Sec. 10336. GAO study and report on Medicare beneficiary access to 
              high-quality dialysis services.

              Subtitle D--Provisions Relating to Title IV

Sec. 10401. Amendments to subtitle A.
Sec. 10402. Amendments to subtitle B.
Sec. 10403. Amendments to subtitle C.
Sec. 10404. Amendments to subtitle D.
Sec. 10405. Amendments to subtitle E.
Sec. 10406. Amendment relating to waiving coinsurance for preventive 
              services.
Sec. 10407. Better diabetes care.
Sec. 10408. Grants for small businesses to provide comprehensive 
              workplace wellness programs.
Sec. 10409. Cures Acceleration Network.
Sec. 10410. Centers of Excellence for Depression.
Sec. 10411. Programs relating to congenital heart disease.
Sec. 10412. Automated Defibrillation in Adam's Memory Act.
Sec. 10413. Young women's breast health awareness and support of young 
              women diagnosed with breast cancer.

               Subtitle E--Provisions Relating to Title V

Sec. 10501. Amendments to the Public Health Service Act, the Social 
              Security Act, and title V of this Act.
Sec. 10502. Infrastructure to Expand Access to Care.
Sec. 10503. Community Health Centers and the National Health Service 
              Corps Fund.
Sec. 10504. Demonstration project to provide access to affordable care.

              Subtitle F--Provisions Relating to Title VI

Sec. 10601. Revisions to limitation on medicare exception to the 
              prohibition on certain physician referrals for hospitals.

[[Page 4207]]

Sec. 10602. Clarifications to patient-centered outcomes research.
Sec. 10603. Striking provisions relating to individual provider 
              application fees.
Sec. 10604. Technical correction to section 6405.
Sec. 10605. Certain other providers permitted to conduct face to face 
              encounter for home health services.
Sec. 10606. Health care fraud enforcement.
Sec. 10607. State demonstration programs to evaluate alternatives to 
              current medical tort litigation.
Sec. 10608. Extension of medical malpractice coverage to free clinics.
Sec. 10609. Labeling changes.

             Subtitle G--Provisions Relating to Title VIII

Sec. 10801. Provisions relating to title VIII.

              Subtitle H--Provisions Relating to Title IX

Sec. 10901. Modifications to excise tax on high cost employer-sponsored 
              health coverage.
Sec. 10902. Inflation adjustment of limitation on health flexible 
              spending arrangements under cafeteria plans.
Sec. 10903. Modification of limitation on charges by charitable 
              hospitals.
Sec. 10904. Modification of annual fee on medical device manufacturers 
              and importers.
Sec. 10905. Modification of annual fee on health insurance providers.
Sec. 10906. Modifications to additional hospital insurance tax on high-
              income taxpayers.
Sec. 10907. Excise tax on indoor tanning services in lieu of elective 
              cosmetic medical procedures.
Sec. 10908. Exclusion for assistance provided to participants in State 
              student loan repayment programs for certain health 
              professionals.
Sec. 10909. Expansion of adoption credit and adoption assistance 
              programs.

       TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

  Subtitle A--Immediate Improvements in Health Care Coverage for All 
                               Americans

     SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

       Part A of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg et seq.) is amended--
       (1) by striking the part heading and inserting the 
     following:

            ``PART A--INDIVIDUAL AND GROUP MARKET REFORMS'';

       (2) by redesignating sections 2704 through 2707 as sections 
     2725 through 2728, respectively;
       (3) by redesignating sections 2711 through 2713 as sections 
     2731 through 2733, respectively;
       (4) by redesignating sections 2721 through 2723 as sections 
     2735 through 2737, respectively; and
       (5) by inserting after section 2702, the following:

                    ``Subpart II--Improving Coverage

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

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not establish--
       ``(1) lifetime limits on the dollar value of benefits for 
     any participant or beneficiary; or
       ``(2) unreasonable annual limits (within the meaning of 
     section 223 of the Internal Revenue Code of 1986) on the 
     dollar value of benefits for any participant or beneficiary.
       ``(b) Per Beneficiary Limits.--Subsection (a) shall not be 
     construed to prevent a group health plan or health insurance 
     coverage that is not required to provide essential health 
     benefits under section 1302(b) of the Patient Protection and 
     Affordable Care Act from placing annual or lifetime per 
     beneficiary limits on specific covered benefits to the extent 
     that such limits are otherwise permitted under Federal or 
     State law.

     ``SEC. 2712. PROHIBITION ON RESCISSIONS.

       ``A group health plan and a health insurance issuer 
     offering group or individual health insurance coverage shall 
     not rescind such plan or coverage with respect to an enrollee 
     once the enrollee is covered under such plan or coverage 
     involved, except that this section shall not apply to a 
     covered individual who has performed an act or practice that 
     constitutes fraud or makes an intentional misrepresentation 
     of material fact as prohibited by the terms of the plan or 
     coverage. Such plan or coverage may not be cancelled except 
     with prior notice to the enrollee, and only as permitted 
     under section 2702(c) or 2742(b).

     ``SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage shall, at a minimum provide coverage for 
     and shall not impose any cost sharing requirements for--
       ``(1) evidence-based items or services that have in effect 
     a rating of `A' or `B' in the current recommendations of the 
     United States Preventive Services Task Force;
       ``(2) immunizations that have in effect a recommendation 
     from the Advisory Committee on Immunization Practices of the 
     Centers for Disease Control and Prevention with respect to 
     the individual involved;
       ``(3) with respect to infants, children, and adolescents, 
     evidence-informed preventive care and screenings provided for 
     in the comprehensive guidelines supported by the Health 
     Resources and Services Administration;
       ``(4) with respect to women, such additional preventive 
     care and screenings not described in paragraph (1) as 
     provided for in comprehensive guidelines supported by the 
     Health Resources and Services Administration for purposes of 
     this paragraph; and
       ``(5) for the purposes of this Act, and for the purposes of 
     any other provision of law, the current recommendations of 
     the United States Preventive Service Task Force regarding 
     breast cancer screening, mammography, and prevention shall be 
     considered the most current other than those issued in or 
     around November 2009.

     Nothing in this subsection shall be construed to prohibit a 
     plan or issuer from providing coverage for services in 
     addition to those recommended by United States Preventive 
     Services Task Force or to deny coverage for services that are 
     not recommended by such Task Force.
       ``(b) Interval.--
       ``(1) In general.--The Secretary shall establish a minimum 
     interval between the date on which a recommendation described 
     in subsection (a)(1) or (a)(2) or a guideline under 
     subsection (a)(3) is issued and the plan year with respect to 
     which the requirement described in subsection (a) is 
     effective with respect to the service described in such 
     recommendation or guideline.
       ``(2) Minimum.--The interval described in paragraph (1) 
     shall not be less than 1 year.
       ``(c) Value-Based Insurance Design.--The Secretary may 
     develop guidelines to permit a group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage to utilize value-based insurance designs.

     ``SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage that provides dependent coverage of 
     children shall continue to make such coverage available for 
     an adult child (who is not married) until the child turns 26 
     years of age. Nothing in this section shall require a health 
     plan or a health insurance issuer described in the preceding 
     sentence to make coverage available for a child of a child 
     receiving dependent coverage.
       ``(b) Regulations.--The Secretary shall promulgate 
     regulations to define the dependents to which coverage shall 
     be made available under subsection (a).
       ``(c) Rule of Construction.--Nothing in this section shall 
     be construed to modify the definition of `dependent' as used 
     in the Internal Revenue Code of 1986 with respect to the tax 
     treatment of the cost of coverage.

     ``SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM 
                   EXPLANATION OF COVERAGE DOCUMENTS AND 
                   STANDARDIZED DEFINITIONS.

       ``(a) In General.--Not later than 12 months after the date 
     of enactment of the Patient Protection and Affordable Care 
     Act, the Secretary shall develop standards for use by a group 
     health plan and a health insurance issuer offering group or 
     individual health insurance coverage, in compiling and 
     providing to enrollees a summary of benefits and coverage 
     explanation that accurately describes the benefits and 
     coverage under the applicable plan or coverage. In developing 
     such standards, the Secretary shall consult with the National 
     Association of Insurance Commissioners (referred to in this 
     section as the `NAIC'), a working group composed of 
     representatives of health insurance-related consumer advocacy 
     organizations, health insurance issuers, health care 
     professionals, patient advocates including those representing 
     individuals with limited English proficiency, and other 
     qualified individuals.
       ``(b) Requirements.--The standards for the summary of 
     benefits and coverage developed under subsection (a) shall 
     provide for the following:
       ``(1) Appearance.--The standards shall ensure that the 
     summary of benefits and coverage is presented in a uniform 
     format that does not exceed 4 pages in length and does not 
     include print smaller than 12-point font.
       ``(2) Language.--The standards shall ensure that the 
     summary is presented in a culturally and linguistically 
     appropriate manner and utilizes terminology understandable by 
     the average plan enrollee.
       ``(3) Contents.--The standards shall ensure that the 
     summary of benefits and coverage includes--
       ``(A) uniform definitions of standard insurance terms and 
     medical terms (consistent with subsection (g)) so that 
     consumers may compare health insurance coverage and 
     understand the terms of coverage (or exception to such 
     coverage);
       ``(B) a description of the coverage, including cost sharing 
     for--
       ``(i) each of the categories of the essential health 
     benefits described in subparagraphs (A) through (J) of 
     section 1302(b)(1) of the Patient Protection and Affordable 
     Care Act; and
       ``(ii) other benefits, as identified by the Secretary;
       ``(C) the exceptions, reductions, and limitations on 
     coverage;
       ``(D) the cost-sharing provisions, including deductible, 
     coinsurance, and co-payment obligations;
       ``(E) the renewability and continuation of coverage 
     provisions;
       ``(F) a coverage facts label that includes examples to 
     illustrate common benefits scenarios, including pregnancy and 
     serious or chronic medical conditions and related cost 
     sharing, such scenarios to be based on recognized clinical 
     practice guidelines;
       ``(G) a statement of whether the plan or coverage--
       ``(i) provides minimum essential coverage (as defined under 
     section 5000A(f) of the Internal Revenue Code 1986); and

[[Page 4208]]

       ``(ii) ensures that the plan or coverage share of the total 
     allowed costs of benefits provided under the plan or coverage 
     is not less than 60 percent of such costs;
       ``(H) a statement that the outline is a summary of the 
     policy or certificate and that the coverage document itself 
     should be consulted to determine the governing contractual 
     provisions; and
       ``(I) a contact number for the consumer to call with 
     additional questions and an Internet web address where a copy 
     of the actual individual coverage policy or group certificate 
     of coverage can be reviewed and obtained.
       ``(c) Periodic Review and Updating.--The Secretary shall 
     periodically review and update, as appropriate, the standards 
     developed under this section.
       ``(d) Requirement To Provide.--
       ``(1) In general.--Not later than 24 months after the date 
     of enactment of the Patient Protection and Affordable Care 
     Act, each entity described in paragraph (3) shall provide, 
     prior to any enrollment restriction, a summary of benefits 
     and coverage explanation pursuant    to the standards 
     developed by the Secretary under subsection (a) to--
       ``(A) an applicant at the time of application;
       ``(B) an enrollee prior to the time of enrollment or 
     reenrollment, as applicable; and
       ``(C) a policyholder or certificate holder at the time of 
     issuance of the policy or delivery of the certificate.
       ``(2) Compliance.--An entity described in paragraph (3) is 
     deemed to be in compliance with this section if the summary 
     of benefits and coverage described in subsection (a) is 
     provided in paper or electronic form.
       ``(3) Entities in general.--An entity described in this 
     paragraph is--
       ``(A) a health insurance issuer (including a group health 
     plan that is not a self-insured plan) offering health 
     insurance coverage within the United States; or
       ``(B) in the case of a self-insured group health plan, the 
     plan sponsor or designated administrator of the plan (as such 
     terms are defined in section 3(16) of the Employee Retirement 
     Income Security Act of 1974).
       ``(4) Notice of modifications.--If a group health plan or 
     health insurance issuer makes any material modification in 
     any of the terms of the plan or coverage involved (as defined 
     for purposes of section 102 of the Employee Retirement Income 
     Security Act of 1974) that is not reflected in the most 
     recently provided summary of benefits and coverage, the plan 
     or issuer shall provide notice of such modification to 
     enrollees not later than 60 days prior to the date on which 
     such modification will become effective.
       ``(e) Preemption.--The standards developed under subsection 
     (a) shall preempt any related State standards that require a 
     summary of benefits and coverage that provides less 
     information to consumers than that required to be provided 
     under this section, as determined by the Secretary.
       ``(f) Failure To Provide.--An entity described in 
     subsection (d)(3) that willfully fails to provide the 
     information required under this section shall be subject to a 
     fine of not more than $1,000 for each such failure. Such 
     failure with respect to each enrollee shall constitute a 
     separate offense for purposes of this subsection.
       ``(g) Development of Standard Definitions.--
       ``(1) In general.--The Secretary shall, by regulation, 
     provide for the development of standards for the definitions 
     of terms used in health insurance coverage, including the 
     insurance-related terms described in paragraph (2) and the 
     medical terms described in paragraph (3).
       ``(2) Insurance-related terms.--The insurance-related terms 
     described in this paragraph are premium, deductible, co-
     insurance, co-payment, out-of-pocket limit, preferred 
     provider, non-preferred provider, out-of-network co-payments, 
     UCR (usual, customary and reasonable) fees, excluded 
     services, grievance and appeals, and such other terms as the 
     Secretary determines are important to define so that 
     consumers may compare health insurance coverage and 
     understand the terms of their coverage.
       ``(3) Medical terms.--The medical terms described in this 
     paragraph are hospitalization, hospital outpatient care, 
     emergency room care, physician services, prescription drug 
     coverage, durable medical equipment, home health care, 
     skilled nursing care, rehabilitation services, hospice 
     services, emergency medical transportation, and such other 
     terms as the Secretary determines are important to define so 
     that consumers may compare the medical benefits offered by 
     health insurance and understand the extent of those medical 
     benefits (or exceptions to those benefits).

     ``SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.

       ``(a) In General.--The plan sponsor of a group health plan 
     (other than a self-insured plan) may not establish rules 
     relating to the health insurance coverage eligibility 
     (including continued eligibility) of any full-time employee 
     under the terms of the plan that are based on the total 
     hourly or annual salary of the employee or otherwise 
     establish eligibility rules that have the effect of 
     discriminating in favor of higher wage employees.
       ``(b) Limitation.--Subsection (a) shall not be construed to 
     prohibit a plan sponsor from establishing contribution 
     requirements for enrollment in the plan or coverage that 
     provide for the payment by employees with lower hourly or 
     annual compensation of a lower dollar or percentage 
     contribution than the payment required of similarly situated 
     employees with a higher hourly or annual compensation.

     ``SEC. 2717. ENSURING THE QUALITY OF CARE.

       ``(a) Quality Reporting.--
       ``(1) In general.--Not later than 2 years after the date of 
     enactment of the Patient Protection and Affordable Care Act, 
     the Secretary, in consultation with experts in health care 
     quality and stakeholders, shall develop reporting 
     requirements for use by a group health plan, and a health 
     insurance issuer offering group or individual health 
     insurance coverage, with respect to plan or coverage benefits 
     and health care provider reimbursement structures that--
       ``(A) improve health outcomes through the implementation of 
     activities such as quality reporting, effective case 
     management, care coordination, chronic disease management, 
     and medication and care compliance initiatives, including 
     through the use of the medical homes model as defined for 
     purposes of section 3602 of the Patient Protection and 
     Affordable Care Act, for treatment or services under the plan 
     or coverage;
       ``(B) implement activities to prevent hospital readmissions 
     through a comprehensive program for hospital discharge that 
     includes patient-centered education and counseling, 
     comprehensive discharge planning, and post discharge 
     reinforcement by an appropriate health care professional;
       ``(C) implement activities to improve patient safety and 
     reduce medical errors through the appropriate use of best 
     clinical practices, evidence based medicine, and health 
     information technology under the plan or coverage; and
       ``(D) implement wellness and health promotion activities.
       ``(2) Reporting requirements.--
       ``(A) In general.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage shall annually submit to the Secretary, 
     and to enrollees under the plan or coverage, a report on 
     whether the benefits under the plan or coverage satisfy the 
     elements described in subparagraphs (A) through (D) of 
     paragraph (1).
       ``(B) Timing of reports.--A report under subparagraph (A) 
     shall be made available to an enrollee under the plan or 
     coverage during each open enrollment period.
       ``(C) Availability of reports.--The Secretary shall make 
     reports submitted under subparagraph (A) available to the 
     public through an Internet website.
       ``(D) Penalties.--In developing the reporting requirements 
     under paragraph (1), the Secretary may develop and impose 
     appropriate penalties for non-compliance with such 
     requirements.
       ``(E) Exceptions.--In developing the reporting requirements 
     under paragraph (1), the Secretary may provide for exceptions 
     to such requirements for group health plans and health 
     insurance issuers that substantially meet the goals of this 
     section.
       ``(b) Wellness and Prevention Programs.--For purposes of 
     subsection (a)(1)(D), wellness and health promotion 
     activities may include personalized wellness and prevention 
     services, which are coordinated, maintained or delivered by a 
     health care provider, a wellness and prevention plan manager, 
     or a health, wellness or prevention services organization 
     that conducts health risk assessments or offers ongoing face-
     to-face, telephonic or web-based intervention efforts for 
     each of the program's participants, and which may include the 
     following wellness and prevention efforts:
       ``(1) Smoking cessation.
       ``(2) Weight management.
       ``(3) Stress management.
       ``(4) Physical fitness.
       ``(5) Nutrition.
       ``(6) Heart disease prevention.
       ``(7) Healthy lifestyle support.
       ``(8) Diabetes prevention.
       ``(c) Regulations.--Not later than 2 years after the date 
     of enactment of the Patient Protection and Affordable Care 
     Act, the Secretary shall promulgate regulations that provide 
     criteria for determining whether a reimbursement structure is 
     described in subsection (a).
       ``(d) Study and Report.--Not later than 180 days after the 
     date on which regulations are promulgated under subsection 
     (c), the Government Accountability Office shall review such 
     regulations and conduct a study and submit to the Committee 
     on Health, Education, Labor, and Pensions of the Senate and 
     the Committee on Energy and Commerce of the House of 
     Representatives a report regarding the impact the activities 
     under this section have had on the quality and cost of health 
     care.

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

       ``(a) Clear Accounting for Costs.--A health insurance 
     issuer offering group or individual health insurance coverage 
     shall, with respect to each plan year, submit to the 
     Secretary a report concerning the percentage of total premium 
     revenue that such coverage expends--
       ``(1) on reimbursement for clinical services provided to 
     enrollees under such coverage;
       ``(2) for activities that improve health care quality; and
       ``(3) on all other non-claims costs, including an 
     explanation of the nature of such costs, and excluding State 
     taxes and licensing or regulatory fees.
     The Secretary shall make reports received under this section 
     available to the public on the Internet website of the 
     Department of Health and Human Services.
       ``(b) Ensuring That Consumers Receive Value for Their 
     Premium Payments.--
       ``(1) Requirement to provide value for premium payments.--A 
     health insurance issuer

[[Page 4209]]

     offering group or individual health insurance coverage shall, 
     with respect to each plan year, provide an annual rebate to 
     each enrollee under such coverage, on a pro rata basis, in an 
     amount that is equal to the amount by which premium revenue 
     expended by the issuer on activities described in subsection 
     (a)(3) exceeds--
       ``(A) with respect to a health insurance issuer offering 
     coverage in the group market, 20 percent, or such lower 
     percentage as a State may by regulation determine; or
       ``(B) with respect to a health insurance issuer offering 
     coverage in the individual market, 25 percent, or such lower 
     percentage as a State may by regulation determine, except 
     that such percentage shall be adjusted to the extent the 
     Secretary determines that the application of such percentage 
     with a State may destabilize the existing individual market 
     in such State.
       ``(2) Consideration in setting percentages.--In determining 
     the percentages under paragraph (1), a State shall seek to 
     ensure adequate participation by health insurance issuers, 
     competition in the health insurance market in the State, and 
     value for consumers so that premiums are used for clinical 
     services and quality improvements.
       ``(3) Termination.--The provisions of this subsection shall 
     have no force or effect after December 31, 2013.
       ``(c) Standard Hospital Charges.--Each hospital operating 
     within the United States shall for each year establish (and 
     update) and make public (in accordance with guidelines 
     developed by the Secretary) a list of the hospital's standard 
     charges for items and services provided by the hospital, 
     including for diagnosis-related groups established under 
     section 1886(d)(4) of the Social Security Act.
       ``(d) Definitions.--The Secretary, in consultation with the 
     National Association of Insurance Commissions, shall 
     establish uniform definitions for the activities reported 
     under subsection (a).

     ``SEC. 2719. APPEALS PROCESS.

       ``A group health plan and a health insurance issuer 
     offering group or individual health insurance coverage shall 
     implement an effective appeals process for appeals of 
     coverage determinations and claims, under which the plan or 
     issuer shall, at a minimum--
       ``(1) have in effect an internal claims appeal process;
       ``(2) provide notice to enrollees, in a culturally and 
     linguistically appropriate manner, of available internal and 
     external appeals processes, and the availability of any 
     applicable office of health insurance consumer assistance or 
     ombudsman established under section 2793 to assist such 
     enrollees with the appeals processes;
       ``(3) allow an enrollee to review their file, to present 
     evidence and testimony as part of the appeals process, and to 
     receive continued coverage pending the outcome of the appeals 
     process; and
       ``(4) provide an external review process for such plans and 
     issuers that, at a minimum, includes the consumer protections 
     set forth in the Uniform External Review Model Act 
     promulgated by the National Association of Insurance 
     Commissioners and is binding on such plans.''.

     SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.

       Part C of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg-91 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.

       ``(a) In General.--The Secretary shall award grants to 
     States to enable such States (or the Exchanges operating in 
     such States) to establish, expand, or provide support for--
       ``(1) offices of health insurance consumer assistance; or
       ``(2) health insurance ombudsman programs.
       ``(b) Eligibility.--
       ``(1) In general.--To be eligible to receive a grant, a 
     State shall designate an independent office of health 
     insurance consumer assistance, or an ombudsman, that, 
     directly or in coordination with State health insurance 
     regulators and consumer assistance organizations, receives 
     and responds to inquiries and complaints concerning health 
     insurance coverage with respect to Federal health insurance 
     requirements and under State law.
       ``(2) Criteria.--A State that receives a grant under this 
     section shall comply with criteria established by the 
     Secretary for carrying out activities under such grant.
       ``(c) Duties.--The office of health insurance consumer 
     assistance or health insurance ombudsman shall--
       ``(1) assist with the filing of complaints and appeals, 
     including filing appeals with the internal appeal or 
     grievance process of the group health plan or health 
     insurance issuer involved and providing information about the 
     external appeal process;
       ``(2) collect, track, and quantify problems and inquiries 
     encountered by consumers;
       ``(3) educate consumers on their rights and 
     responsibilities with respect to group health plans and 
     health insurance coverage;
       ``(4) assist consumers with enrollment in a group health 
     plan or health insurance coverage by providing information, 
     referral, and assistance; and
       ``(5) resolve problems with obtaining premium tax credits 
     under section 36B of the Internal Revenue Code of 1986.
       ``(d) Data Collection.--As a condition of receiving a grant 
     under subsection (a), an office of health insurance consumer 
     assistance or ombudsman program shall be required to collect 
     and report data to the Secretary on the types of problems and 
     inquiries encountered by consumers. The Secretary shall 
     utilize such data to identify areas where more enforcement 
     action is necessary and shall share such information with 
     State insurance regulators, the Secretary of Labor, and the 
     Secretary of the Treasury for use in the enforcement 
     activities of such agencies.
       ``(e) Funding.--
       ``(1) Initial funding.--There is hereby appropriated to the 
     Secretary, out of any funds in the Treasury not otherwise 
     appropriated, $30,000,000 for the first fiscal year for which 
     this section applies to carry out this section. Such amount 
     shall remain available without fiscal year limitation.
       ``(2) Authorization for subsequent years.--There is 
     authorized to be appropriated to the Secretary for each 
     fiscal year following the fiscal year described in paragraph 
     (1), such sums as may be necessary to carry out this 
     section.''.

     SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR 
                   DOLLARS.

       Part C of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg-91 et seq.), as amended by section 1002, is 
     further amended by adding at the end the following:

     ``SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR 
                   DOLLARS.

       ``(a) Initial Premium Review Process.--
       ``(1) In general.--The Secretary, in conjunction with 
     States, shall establish a process for the annual review, 
     beginning with the 2010 plan year and subject to subsection 
     (b)(2)(A), of unreasonable increases in premiums for health 
     insurance coverage.
       ``(2) Justification and disclosure.--The process 
     established under paragraph (1) shall require health 
     insurance issuers to submit to the Secretary and the relevant 
     State a justification for an unreasonable premium increase 
     prior to the implementation of the increase. Such issuers 
     shall prominently post such information on their Internet 
     websites. The Secretary shall ensure the public disclosure of 
     information on such increases and justifications for all 
     health insurance issuers.
       ``(b) Continuing Premium Review Process.--
       ``(1) Informing secretary of premium increase patterns.--As 
     a condition of receiving a grant under subsection (c)(1), a 
     State, through its Commissioner of Insurance, shall--
       ``(A) provide the Secretary with information about trends 
     in premium increases in health insurance coverage in premium 
     rating areas in the State; and
       ``(B) make recommendations, as appropriate, to the State 
     Exchange about whether particular health insurance issuers 
     should be excluded from participation in the Exchange based 
     on a pattern or practice of excessive or unjustified premium 
     increases.
       ``(2) Monitoring by secretary of premium increases.--
       ``(A) In general.--Beginning with plan years beginning in 
     2014, the Secretary, in conjunction with the States and 
     consistent with the provisions of subsection (a)(2), shall 
     monitor premium increases of health insurance coverage 
     offered through an Exchange and outside of an Exchange.
       ``(B) Consideration in opening exchange.--In determining 
     under section 1312(f)(2)(B) of the Patient Protection and 
     Affordable Care Act whether to offer qualified health plans 
     in the large group market through an Exchange, the State 
     shall take into account any excess of premium growth outside 
     of the Exchange as compared to the rate of such growth inside 
     the Exchange.
       ``(c) Grants in Support of Process.--
       ``(1) Premium review grants during 2010 through 2014.--The 
     Secretary shall carry out a program to award grants to States 
     during the 5-year period beginning with fiscal year 2010 to 
     assist such States in carrying out subsection (a), 
     including--
       ``(A) in reviewing and, if appropriate under State law, 
     approving premium increases for health insurance coverage; 
     and
       ``(B) in providing information and recommendations to the 
     Secretary under subsection (b)(1).
       ``(2) Funding.--
       ``(A) In general.--Out of all funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary $250,000,000, to be available for expenditure for 
     grants under paragraph (1) and subparagraph (B).
       ``(B) Further availability for insurance reform and 
     consumer protection.--If the amounts appropriated under 
     subparagraph (A) are not fully obligated under grants under 
     paragraph (1) by the end of fiscal year 2014, any remaining 
     funds shall remain available to the Secretary for grants to 
     States for planning and implementing the insurance reforms 
     and consumer protections under part A.
       ``(C) Allocation.--The Secretary shall establish a formula 
     for determining the amount of any grant to a State under this 
     subsection. Under such formula--
       ``(i) the Secretary shall consider the number of plans of 
     health insurance coverage offered in each State and the 
     population of the State; and
       ``(ii) no State qualifying for a grant under paragraph (1) 
     shall receive less than $1,000,000, or more than $5,000,000 
     for a grant year.''.

     SEC. 1004. EFFECTIVE DATES.

       (a) In General.--Except as provided for in subsection (b), 
     this subtitle (and the amendments made by this subtitle) 
     shall become effective for plan years beginning on or after 
     the date that is 6 months after the date of enactment of this 
     Act, except that the amendments

[[Page 4210]]

     made by sections 1002 and 1003 shall become effective for 
     fiscal years beginning with fiscal year 2010.
       (b) Special Rule.--The amendments made by sections 1002 and 
     1003 shall take effect on the date of enactment of this Act.

     Subtitle B--Immediate Actions to Preserve and Expand Coverage

     SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED 
                   INDIVIDUALS WITH A PREEXISTING CONDITION.

       (a) In General.--Not later than 90 days after the date of 
     enactment of this Act, the Secretary shall establish a 
     temporary high risk health insurance pool program to provide 
     health insurance coverage for eligible individuals during the 
     period beginning on the date on which such program is 
     established and ending on January 1, 2014.
       (b) Administration.--
       (1) In general.--The Secretary may carry out the program 
     under this section directly or through contracts to eligible 
     entities.
       (2) Eligible entities.--To be eligible for a contract under 
     paragraph (1), an entity shall--
       (A) be a State or nonprofit private entity;
       (B) submit to the Secretary an application at such time, in 
     such manner, and containing such information as the Secretary 
     may require; and
       (C) agree to utilize contract funding to establish and 
     administer a qualified high risk pool for eligible 
     individuals.
       (3) Maintenance of effort.--To be eligible to enter into a 
     contract with the Secretary under this subsection, a State 
     shall agree not to reduce the annual amount the State 
     expended for the operation of one or more State high risk 
     pools during the year preceding the year in which such 
     contract is entered into.
       (c) Qualified High Risk Pool.--
       (1) In general.--Amounts made available under this section 
     shall be used to establish a qualified high risk pool that 
     meets the requirements of paragraph (2).
       (2) Requirements.--A qualified high risk pool meets the 
     requirements of this paragraph if such pool--
       (A) provides to all eligible individuals health insurance 
     coverage that does not impose any preexisting condition 
     exclusion with respect to such coverage;
       (B) provides health insurance coverage--
       (i) in which the issuer's share of the total allowed costs 
     of benefits provided under such coverage is not less than 65 
     percent of such costs; and
       (ii) that has an out of pocket limit not greater than the 
     applicable amount described in section 223(c)(2) of the 
     Internal Revenue Code of 1986 for the year involved, except 
     that the Secretary may modify such limit if necessary to 
     ensure the pool meets the actuarial value limit under clause 
     (i);
       (C) ensures that with respect to the premium rate charged 
     for health insurance coverage offered to eligible individuals 
     through the high risk pool, such rate shall--
       (i) except as provided in clause (ii), vary only as 
     provided for under section 2701 of the Public Health Service 
     Act (as amended by this Act and notwithstanding the date on 
     which such amendments take effect);
       (ii) vary on the basis of age by a factor of not greater 
     than 4 to 1; and
       (iii) be established at a standard rate for a standard 
     population; and
       (D) meets any other requirements determined appropriate by 
     the Secretary.
       (d) Eligible Individual.--An individual shall be deemed to 
     be an eligible individual for purposes of this section if 
     such individual--
       (1) is a citizen or national of the United States or is 
     lawfully present in the United States (as determined in 
     accordance with section 1411);
       (2) has not been covered under creditable coverage (as 
     defined in section 2701(c)(1) of the Public Health Service 
     Act as in effect on the date of enactment of this Act) during 
     the 6-month period prior to the date on which such individual 
     is applying for coverage through the high risk pool; and
       (3) has a pre-existing condition, as determined in a manner 
     consistent with guidance issued by the Secretary.
       (e) Protection Against Dumping Risk by Insurers.--
       (1) In general.--The Secretary shall establish criteria for 
     determining whether health insurance issuers and employment-
     based health plans have discouraged an individual from 
     remaining enrolled in prior coverage based on that 
     individual's health status.
       (2) Sanctions.--An issuer or employment-based health plan 
     shall be responsible for reimbursing the program under this 
     section for the medical expenses incurred by the program for 
     an individual who, based on criteria established by the 
     Secretary, the Secretary finds was encouraged by the issuer 
     to disenroll from health benefits coverage prior to enrolling 
     in coverage through the program. The criteria shall include 
     at least the following circumstances:
       (A) In the case of prior coverage obtained through an 
     employer, the provision by the employer, group health plan, 
     or the issuer of money or other financial consideration for 
     disenrolling from the coverage.
       (B) In the case of prior coverage obtained directly from an 
     issuer or under an employment-based health plan--
       (i) the provision by the issuer or plan of money or other 
     financial consideration for disenrolling from the coverage; 
     or
       (ii) in the case of an individual whose premium for the 
     prior coverage exceeded the premium required by the program 
     (adjusted based on the age factors applied to the prior 
     coverage)--

       (I) the prior coverage is a policy that is no longer being 
     actively marketed (as defined by the Secretary) by the 
     issuer; or
       (II) the prior coverage is a policy for which duration of 
     coverage form issue or health status are factors that can be 
     considered in determining premiums at renewal.

       (3) Construction.--Nothing in this subsection shall be 
     construed as constituting exclusive remedies for violations 
     of criteria established under paragraph (1) or as preventing 
     States from applying or enforcing such paragraph or other 
     provisions under law with respect to health insurance 
     issuers.
       (f) Oversight.--The Secretary shall establish--
       (1) an appeals process to enable individuals to appeal a 
     determination under this section; and
       (2) procedures to protect against waste, fraud, and abuse.
       (g) Funding; Termination of Authority.--
       (1) In general.--There is appropriated to the Secretary, 
     out of any moneys in the Treasury not otherwise appropriated, 
     $5,000,000,000 to pay claims against (and the administrative 
     costs of) the high risk pool under this section that are in 
     excess of the amount of premiums collected from eligible 
     individuals enrolled in the high risk pool. Such funds shall 
     be available without fiscal year limitation.
       (2) Insufficient funds.--If the Secretary estimates for any 
     fiscal year that the aggregate amounts available for the 
     payment of the expenses of the high risk pool will be less 
     than the actual amount of such expenses, the Secretary shall 
     make such adjustments as are necessary to eliminate such 
     deficit.
       (3) Termination of authority.--
       (A) In general.--Except as provided in subparagraph (B), 
     coverage of eligible individuals under a high risk pool in a 
     State shall terminate on January 1, 2014.
       (B) Transition to exchange.--The Secretary shall develop 
     procedures to provide for the transition of eligible 
     individuals enrolled in health insurance coverage offered 
     through a high risk pool established under this section into 
     qualified health plans offered through an Exchange. Such 
     procedures shall ensure that there is no lapse in coverage 
     with respect to the individual and may extend coverage after 
     the termination of the risk pool involved, if the Secretary 
     determines necessary to avoid such a lapse.
       (4) Limitations.--The Secretary has the authority to stop 
     taking applications for participation in the program under 
     this section to comply with the funding limitation provided 
     for in paragraph (1).
       (5) Relation to state laws.--The standards established 
     under this section shall supersede any State law or 
     regulation (other than State licensing laws or State laws 
     relating to plan solvency) with respect to qualified high 
     risk pools which are established in accordance with this 
     section.

     SEC. 1102. REINSURANCE FOR EARLY RETIREES.

       (a) Administration.--
       (1) In general.--Not later than 90 days after the date of 
     enactment of this Act, the Secretary shall establish a 
     temporary reinsurance program to provide reimbursement to 
     participating employment-based plans for a portion of the 
     cost of providing health insurance coverage to early retirees 
     (and to the eligible spouses, surviving spouses, and 
     dependents of such retirees) during the period beginning on 
     the date on which such program is established and ending on 
     January 1, 2014.
       (2) Reference.--In this section:
       (A) Health benefits.--The term ``health benefits'' means 
     medical, surgical, hospital, prescription drug, and such 
     other benefits as shall be determined by the Secretary, 
     whether self-funded, or delivered through the purchase of 
     insurance or otherwise.
       (B) Employment-based plan.--The term ``employment-based 
     plan'' means a group health benefits plan that--
       (i) is--

       (I) maintained by one or more current or former employers 
     (including without limitation any State or local government 
     or political subdivision thereof), employee organization, a 
     voluntary employees' beneficiary association, or a committee 
     or board of individuals appointed to administer such plan; or
       (II) a multiemployer plan (as defined in section 3(37) of 
     the Employee Retirement Income Security Act of 1974); and

       (ii) provides health benefits to early retirees.
       (C) Early retirees.--The term ``early retirees'' means 
     individuals who are age 55 and older but are not eligible for 
     coverage under title XVIII of the Social Security Act, and 
     who are not active employees of an employer maintaining, or 
     currently contributing to, the employment-based plan or of 
     any employer that has made substantial contributions to fund 
     such plan.
       (b) Participation.--
       (1) Employment-based plan eligibility.--A participating 
     employment-based plan is an employment-based plan that--
       (A) meets the requirements of paragraph (2) with respect to 
     health benefits provided under the plan; and
       (B) submits to the Secretary an application for 
     participation in the program, at such time, in such manner, 
     and containing such information as the Secretary shall 
     require.
       (2) Employment-based health benefits.--An employment-based 
     plan meets the requirements of this paragraph if the plan--
       (A) implements programs and procedures to generate cost-
     savings with respect to participants with chronic and high-
     cost conditions;

[[Page 4211]]

       (B) provides documentation of the actual cost of medical 
     claims involved; and
       (C) is certified by the Secretary.
       (c) Payments.--
       (1) Submission of claims.--
       (A) In general.--A participating employment-based plan 
     shall submit claims for reimbursement to the Secretary which 
     shall contain documentation of the actual costs of the items 
     and services for which each claim is being submitted.
       (B) Basis for claims.--Claims submitted under subparagraph 
     (A) shall be based on the actual amount expended by the 
     participating employment-based plan involved within the plan 
     year for the health benefits provided to an early retiree or 
     the spouse, surviving spouse, or dependent of such retiree. 
     In determining the amount of a claim for purposes of this 
     subsection, the participating employment-based plan shall 
     take into account any negotiated price concessions (such as 
     discounts, direct or indirect subsidies, rebates, and direct 
     or indirect remunerations) obtained by such plan with respect 
     to such health benefit. For purposes of determining the 
     amount of any such claim, the costs paid by the early retiree 
     or the retiree's spouse, surviving spouse, or dependent in 
     the form of deductibles, co-payments, or co-insurance shall 
     be included in the amounts paid by the participating 
     employment-based plan.
       (2) Program payments.--If the Secretary determines that a 
     participating employment-based plan has submitted a valid 
     claim under paragraph (1), the Secretary shall reimburse such 
     plan for 80 percent of that portion of the costs attributable 
     to such claim that exceed $15,000, subject to the limits 
     contained in paragraph (3).
       (3) Limit.--To be eligible for reimbursement under the 
     program, a claim submitted by a participating employment-
     based plan shall not be less than $15,000 nor greater than 
     $90,000. Such amounts shall be adjusted each fiscal year 
     based on the percentage increase in the Medical Care 
     Component of the Consumer Price Index for all urban consumers 
     (rounded to the nearest multiple of $1,000) for the year 
     involved.
       (4) Use of payments.--Amounts paid to a participating 
     employment-based plan under this subsection shall be used to 
     lower costs for the plan. Such payments may be used to reduce 
     premium costs for an entity described in subsection 
     (a)(2)(B)(i) or to reduce premium contributions, co-payments, 
     deductibles, co-insurance, or other out-of-pocket costs for 
     plan participants. Such payments shall not be used as general 
     revenues for an entity described in subsection (a)(2)(B)(i). 
     The Secretary shall develop a mechanism to monitor the 
     appropriate use of such payments by such entities.
       (5) Payments not treated as income.--Payments received 
     under this subsection shall not be included in determining 
     the gross income of an entity described in subsection 
     (a)(2)(B)(i) that is maintaining or currently contributing to 
     a participating employment-based plan.
       (6) Appeals.--The Secretary shall establish--
       (A) an appeals process to permit participating employment-
     based plans to appeal a determination of the Secretary with 
     respect to claims submitted under this section; and
       (B) procedures to protect against fraud, waste, and abuse 
     under the program.
       (d) Audits.--The Secretary shall conduct annual audits of 
     claims data submitted by participating employment-based plans 
     under this section to ensure that such plans are in 
     compliance with the requirements of this section.
       (e) Funding.--There is appropriated to the Secretary, out 
     of any moneys in the Treasury not otherwise appropriated, 
     $5,000,000,000 to carry out the program under this section. 
     Such funds shall be available without fiscal year limitation.
       (f) Limitation.--The Secretary has the authority to stop 
     taking applications for participation in the program based on 
     the availability of funding under subsection (e).

     SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO 
                   IDENTIFY AFFORDABLE COVERAGE OPTIONS.

       (a) Internet Portal to Affordable Coverage Options.--
       (1) Immediate establishment.--Not later than July 1, 2010, 
     the Secretary, in consultation with the States, shall 
     establish a mechanism, including an Internet website, through 
     which a resident of any State may identify affordable health 
     insurance coverage options in that State.
       (2) Connecting to affordable coverage.--An Internet website 
     established under paragraph (1) shall, to the extent 
     practicable, provide ways for residents of any State to 
     receive information on at least the following coverage 
     options:
       (A) Health insurance coverage offered by health insurance 
     issuers, other than coverage that provides reimbursement only 
     for the treatment or mitigation of--
       (i) a single disease or condition; or
       (ii) an unreasonably limited set of diseases or conditions 
     (as determined by the Secretary);
       (B) Medicaid coverage under title XIX of the Social 
     Security Act.
       (C) Coverage under title XXI of the Social Security Act.
       (D) A State health benefits high risk pool, to the extent 
     that such high risk pool is offered in such State; and
       (E) Coverage under a high risk pool under section 1101.
       (b) Enhancing Comparative Purchasing Options.--
       (1) In general.--Not later than 60 days after the date of 
     enactment of this Act, the Secretary shall develop a 
     standardized format to be used for the presentation of 
     information relating to the coverage options described in 
     subsection (a)(2). Such format shall, at a minimum, require 
     the inclusion of information on the percentage of total 
     premium revenue expended on nonclinical costs (as reported 
     under section 2718(a) of the Public Health Service Act), 
     eligibility, availability, premium rates, and cost sharing 
     with respect to such coverage options and be consistent with 
     the standards adopted for the uniform explanation of coverage 
     as provided for in section 2715 of the Public Health Service 
     Act.
       (2) Use of format.--The Secretary shall utilize the format 
     developed under paragraph (1) in compiling information 
     concerning coverage options on the Internet website 
     established under subsection (a).
       (c) Authority To Contract.--The Secretary may carry out 
     this section through contracts entered into with qualified 
     entities.

     SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.

       (a) Purpose of Administrative Simplification.--Section 261 
     of the Health Insurance Portability and Accountability Act of 
     1996 (42 U.S.C. 1320d note) is amended--
       (1) by inserting ``uniform'' before ``standards''; and
       (2) by inserting ``and to reduce the clerical burden on 
     patients, health care providers, and health plans'' before 
     the period at the end.
       (b) Operating Rules for Health Information Transactions.--
       (1) Definition of operating rules.--Section 1171 of the 
     Social Security Act (42 U.S.C. 1320d) is amended by adding at 
     the end the following:
       ``(9) Operating rules.--The term `operating rules' means 
     the necessary business rules and guidelines for the 
     electronic exchange of information that are not defined by a 
     standard or its implementation specifications as adopted for 
     purposes of this part.''.
       (2) Transaction standards; operating rules and 
     compliance.--Section 1173 of the Social Security Act (42 
     U.S.C. 1320d-2) is amended--
       (A) in subsection (a)(2), by adding at the end the 
     following new subparagraph:
       ``(J) Electronic funds transfers.'';
       (B) in subsection (a), by adding at the end the following 
     new paragraph:
       ``(4) Requirements for financial and administrative 
     transactions.--
       ``(A) In general.--The standards and associated operating 
     rules adopted by the Secretary shall--
       ``(i) to the extent feasible and appropriate, enable 
     determination of an individual's eligibility and financial 
     responsibility for specific services prior to or at the point 
     of care;
       ``(ii) be comprehensive, requiring minimal augmentation by 
     paper or other communications;
       ``(iii) provide for timely acknowledgment, response, and 
     status reporting that supports a transparent claims and 
     denial management process (including adjudication and 
     appeals); and
       ``(iv) describe all data elements (including reason and 
     remark codes) in unambiguous terms, require that such data 
     elements be required or conditioned upon set values in other 
     fields, and prohibit additional conditions (except where 
     necessary to implement State or Federal law, or to protect 
     against fraud and abuse).
       ``(B) Reduction of clerical burden.--In adopting standards 
     and operating rules for the transactions referred to under 
     paragraph (1), the Secretary shall seek to reduce the number 
     and complexity of forms (including paper and electronic 
     forms) and data entry required by patients and providers.''; 
     and
       (C) by adding at the end the following new subsections:
       ``(g) Operating Rules.--
       ``(1) In general.--The Secretary shall adopt a single set 
     of operating rules for each transaction referred to under 
     subsection (a)(1) with the goal of creating as much 
     uniformity in the implementation of the electronic standards 
     as possible. Such operating rules shall be consensus-based 
     and reflect the necessary business rules affecting health 
     plans and health care providers and the manner in which they 
     operate pursuant to standards issued under Health Insurance 
     Portability and Accountability Act of 1996.
       ``(2) Operating rules development.--In adopting operating 
     rules under this subsection, the Secretary shall consider 
     recommendations for operating rules developed by a qualified 
     nonprofit entity that meets the following requirements:
       ``(A) The entity focuses its mission on administrative 
     simplification.
       ``(B) The entity demonstrates a multi-stakeholder and 
     consensus-based process for development of operating rules, 
     including representation by or participation from health 
     plans, health care providers, vendors, relevant Federal 
     agencies, and other standard development organizations.
       ``(C) The entity has a public set of guiding principles 
     that ensure the operating rules and process are open and 
     transparent, and supports nondiscrimination and conflict of 
     interest policies that demonstrate a commitment to open, 
     fair, and nondiscriminatory practices.
       ``(D) The entity builds on the transaction standards issued 
     under Health Insurance Portability and Accountability Act of 
     1996.
       ``(E) The entity allows for public review and updates of 
     the operating rules.
       ``(3) Review and recommendations.--The National Committee 
     on Vital and Health Statistics shall--
       ``(A) advise the Secretary as to whether a nonprofit entity 
     meets the requirements under paragraph (2);
       ``(B) review the operating rules developed and recommended 
     by such nonprofit entity;

[[Page 4212]]

       ``(C) determine whether such operating rules represent a 
     consensus view of the health care stakeholders and are 
     consistent with and do not conflict with other existing 
     standards;
       ``(D) evaluate whether such operating rules are consistent 
     with electronic standards adopted for health information 
     technology; and
       ``(E) submit to the Secretary a recommendation as to 
     whether the Secretary should adopt such operating rules.
       ``(4) Implementation.--
       ``(A) In general.--The Secretary shall adopt operating 
     rules under this subsection, by regulation in accordance with 
     subparagraph (C), following consideration of the operating 
     rules developed by the non-profit entity described in 
     paragraph (2) and the recommendation submitted by the 
     National Committee on Vital and Health Statistics under 
     paragraph (3)(E) and having ensured consultation with 
     providers.
       ``(B) Adoption requirements; effective dates.--
       ``(i) Eligibility for a health plan and health claim 
     status.--The set of operating rules for eligibility for a 
     health plan and health claim status transactions shall be 
     adopted not later than July 1, 2011, in a manner ensuring 
     that such operating rules are effective not later than 
     January 1, 2013, and may allow for the use of a machine 
     readable identification card.
       ``(ii) Electronic funds transfers and health care payment 
     and remittance advice.--The set of operating rules for 
     electronic funds transfers and health care payment and 
     remittance advice transactions shall--

       ``(I) allow for automated reconciliation of the electronic 
     payment with the remittance advice; and
       ``(II) be adopted not later than July 1, 2012, in a manner 
     ensuring that such operating rules are effective not later 
     than January 1, 2014.

       ``(iii) Health claims or equivalent encounter information, 
     enrollment and disenrollment in a health plan, health plan 
     premium payments, referral certification and authorization.--
     The set of operating rules for health claims or equivalent 
     encounter information, enrollment and disenrollment in a 
     health plan, health plan premium payments, and referral 
     certification and authorization transactions shall be adopted 
     not later than July 1, 2014, in a manner ensuring that such 
     operating rules are effective not later than January 1, 2016.
       ``(C) Expedited rulemaking.--The Secretary shall promulgate 
     an interim final rule applying any standard or operating rule 
     recommended by the National Committee on Vital and Health 
     Statistics pursuant to paragraph (3). The Secretary shall 
     accept and consider public comments on any interim final rule 
     published under this subparagraph for 60 days after the date 
     of such publication.
       ``(h) Compliance.--
       ``(1) Health plan certification.--
       ``(A) Eligibility for a health plan, health claim status, 
     electronic funds transfers, health care payment and 
     remittance advice.--Not later than December 31, 2013, a 
     health plan shall file a statement with the Secretary, in 
     such form as the Secretary may require, certifying that the 
     data and information systems for such plan are in compliance 
     with any applicable standards (as described under paragraph 
     (7) of section 1171) and associated operating rules (as 
     described under paragraph (9) of such section) for electronic 
     funds transfers, eligibility for a health plan, health claim 
     status, and health care payment and remittance advice, 
     respectively.
       ``(B) Health claims or equivalent encounter information, 
     enrollment and disenrollment in a health plan, health plan 
     premium payments, health claims attachments, referral 
     certification and authorization.--Not later than December 31, 
     2015, a health plan shall file a statement with the 
     Secretary, in such form as the Secretary may require, 
     certifying that the data and information systems for such 
     plan are in compliance with any applicable standards and 
     associated operating rules for health claims or equivalent 
     encounter information, enrollment and disenrollment in a 
     health plan, health plan premium payments, health claims 
     attachments, and referral certification and authorization, 
     respectively. A health plan shall provide the same level of 
     documentation to certify compliance with such transactions as 
     is required to certify compliance with the transactions 
     specified in subparagraph (A).
       ``(2) Documentation of compliance.--A health plan shall 
     provide the Secretary, in such form as the Secretary may 
     require, with adequate documentation of compliance with the 
     standards and operating rules described under paragraph (1). 
     A health plan shall not be considered to have provided 
     adequate documentation and shall not be certified as being in 
     compliance with such standards, unless the health plan--
       ``(A) demonstrates to the Secretary that the plan conducts 
     the electronic transactions specified in paragraph (1) in a 
     manner that fully complies with the regulations of the 
     Secretary; and
       ``(B) provides documentation showing that the plan has 
     completed end-to-end testing for such transactions with their 
     partners, such as hospitals and physicians.
       ``(3) Service contracts.--A health plan shall be required 
     to ensure that any entities that provide services pursuant to 
     a contract with such health plan shall comply with any 
     applicable certification and compliance requirements (and 
     provide the Secretary with adequate documentation of such 
     compliance) under this subsection.
       ``(4) Certification by outside entity.--The Secretary may 
     designate independent, outside entities to certify that a 
     health plan has complied with the requirements under this 
     subsection, provided that the certification standards 
     employed by such entities are in accordance with any 
     standards or operating rules issued by the Secretary.
       ``(5) Compliance with revised standards and operating 
     rules.--
       ``(A) In general.--A health plan (including entities 
     described under paragraph (3)) shall file a statement with 
     the Secretary, in such form as the Secretary may require, 
     certifying that the data and information systems for such 
     plan are in compliance with any applicable revised standards 
     and associated operating rules under this subsection for any 
     interim final rule promulgated by the Secretary under 
     subsection (i) that--
       ``(i) amends any standard or operating rule described under 
     paragraph (1) of this subsection; or
       ``(ii) establishes a standard (as described under 
     subsection (a)(1)(B)) or associated operating rules (as 
     described under subsection (i)(5)) for any other financial 
     and administrative transactions.
       ``(B) Date of compliance.--A health plan shall comply with 
     such requirements not later than the effective date of the 
     applicable standard or operating rule.
       ``(6) Audits of health plans.--The Secretary shall conduct 
     periodic audits to ensure that health plans (including 
     entities described under paragraph (3)) are in compliance 
     with any standards and operating rules that are described 
     under paragraph (1) or subsection (i)(5).
       ``(i) Review and Amendment of Standards and Operating 
     Rules.--
       ``(1) Establishment.--Not later than January 1, 2014, the 
     Secretary shall establish a review committee (as described 
     under paragraph (4)).
       ``(2) Evaluations and reports.--
       ``(A) Hearings.--Not later than April 1, 2014, and not less 
     than biennially thereafter, the Secretary, acting through the 
     review committee, shall conduct hearings to evaluate and 
     review the adopted standards and operating rules established 
     under this section.
       ``(B) Report.--Not later than July 1, 2014, and not less 
     than biennially thereafter, the review committee shall 
     provide recommendations for updating and improving such 
     standards and operating rules. The review committee shall 
     recommend a single set of operating rules per transaction 
     standard and maintain the goal of creating as much uniformity 
     as possible in the implementation of the electronic 
     standards.
       ``(3) Interim final rulemaking.--
       ``(A) In general.--Any recommendations to amend adopted 
     standards and operating rules that have been approved by the 
     review committee and reported to the Secretary under 
     paragraph (2)(B) shall be adopted by the Secretary through 
     promulgation of an interim final rule not later than 90 days 
     after receipt of the committee's report.
       ``(B) Public comment.--
       ``(i) Public comment period.--The Secretary shall accept 
     and consider public comments on any interim final rule 
     published under this paragraph for 60 days after the date of 
     such publication.
       ``(ii) Effective date.--The effective date of any amendment 
     to existing standards or operating rules that is adopted 
     through an interim final rule published under this paragraph 
     shall be 25 months following the close of such public comment 
     period.
       ``(4) Review committee.--
       ``(A) Definition.--For the purposes of this subsection, the 
     term `review committee' means a committee chartered by or 
     within the Department of Health and Human services that has 
     been designated by the Secretary to carry out this 
     subsection, including--
       ``(i) the National Committee on Vital and Health 
     Statistics; or
       ``(ii) any appropriate committee as determined by the 
     Secretary.
       ``(B) Coordination of hit standards.--In developing 
     recommendations under this subsection, the review committee 
     shall ensure coordination, as appropriate, with the standards 
     that support the certified electronic health record 
     technology approved by the Office of the National Coordinator 
     for Health Information Technology.
       ``(5) Operating rules for other standards adopted by the 
     secretary.--The Secretary shall adopt a single set of 
     operating rules (pursuant to the process described under 
     subsection (g)) for any transaction for which a standard had 
     been adopted pursuant to subsection (a)(1)(B).
       ``(j) Penalties.--
       ``(1) Penalty fee.--
       ``(A) In general.--Not later than April 1, 2014, and 
     annually thereafter, the Secretary shall assess a penalty fee 
     (as determined under subparagraph (B)) against a health plan 
     that has failed to meet the requirements under subsection (h) 
     with respect to certification and documentation of compliance 
     with--
       ``(i) the standards and associated operating rules 
     described under paragraph (1) of such subsection; and
       ``(ii) a standard (as described under subsection (a)(1)(B)) 
     and associated operating rules (as described under subsection 
     (i)(5)) for any other financial and administrative 
     transactions.
       ``(B) Fee amount.--Subject to subparagraphs (C), (D), and 
     (E), the Secretary shall assess a penalty fee against a 
     health plan in the amount of $1 per covered life until 
     certification is complete. The penalty shall be assessed per 
     person

[[Page 4213]]

     covered by the plan for which its data systems for major 
     medical policies are not in compliance and shall be imposed 
     against the health plan for each day that the plan is not in 
     compliance with the requirements under subsection (h).
       ``(C) Additional penalty for misrepresentation.--A health 
     plan that knowingly provides inaccurate or incomplete 
     information in a statement of certification or documentation 
     of compliance under subsection (h) shall be subject to a 
     penalty fee that is double the amount that would otherwise be 
     imposed under this subsection.
       ``(D) Annual fee increase.--The amount of the penalty fee 
     imposed under this subsection shall be increased on an annual 
     basis by the annual percentage increase in total national 
     health care expenditures, as determined by the Secretary.
       ``(E) Penalty limit.--A penalty fee assessed against a 
     health plan under this subsection shall not exceed, on an 
     annual basis--
       ``(i) an amount equal to $20 per covered life under such 
     plan; or
       ``(ii) an amount equal to $40 per covered life under the 
     plan if such plan has knowingly provided inaccurate or 
     incomplete information (as described under subparagraph (C)).
       ``(F) Determination of covered individuals.--The Secretary 
     shall determine the number of covered lives under a health 
     plan based upon the most recent statements and filings that 
     have been submitted by such plan to the Securities and 
     Exchange Commission.
       ``(2) Notice and dispute procedure.--The Secretary shall 
     establish a procedure for assessment of penalty fees under 
     this subsection that provides a health plan with reasonable 
     notice and a dispute resolution procedure prior to provision 
     of a notice of assessment by the Secretary of the Treasury 
     (as described under paragraph (4)(B)).
       ``(3) Penalty fee report.--Not later than May 1, 2014, and 
     annually thereafter, the Secretary shall provide the 
     Secretary of the Treasury with a report identifying those 
     health plans that have been assessed a penalty fee under this 
     subsection.
       ``(4) Collection of penalty fee.--
       ``(A) In general.--The Secretary of the Treasury, acting 
     through the Financial Management Service, shall administer 
     the collection of penalty fees from health plans that have 
     been identified by the Secretary in the penalty fee report 
     provided under paragraph (3).
       ``(B) Notice.--Not later than August 1, 2014, and annually 
     thereafter, the Secretary of the Treasury shall provide 
     notice to each health plan that has been assessed a penalty 
     fee by the Secretary under this subsection. Such notice shall 
     include the amount of the penalty fee assessed by the 
     Secretary and the due date for payment of such fee to the 
     Secretary of the Treasury (as described in subparagraph (C)).
       ``(C) Payment due date.--Payment by a health plan for a 
     penalty fee assessed under this subsection shall be made to 
     the Secretary of the Treasury not later than November 1, 
     2014, and annually thereafter.
       ``(D) Unpaid penalty fees.--Any amount of a penalty fee 
     assessed against a health plan under this subsection for 
     which payment has not been made by the due date provided 
     under subparagraph (C) shall be--
       ``(i) increased by the interest accrued on such amount, as 
     determined pursuant to the underpayment rate established 
     under section 6621 of the Internal Revenue Code of 1986; and
       ``(ii) treated as a past-due, legally enforceable debt owed 
     to a Federal agency for purposes of section 6402(d) of the 
     Internal Revenue Code of 1986.
       ``(E) Administrative fees.--Any fee charged or allocated 
     for collection activities conducted by the Financial 
     Management Service will be passed on to a health plan on a 
     pro-rata basis and added to any penalty fee collected from 
     the plan.''.
       (c) Promulgation of Rules.--
       (1) Unique health plan identifier.--The Secretary shall 
     promulgate a final rule to establish a unique health plan 
     identifier (as described in section 1173(b) of the Social 
     Security Act (42 U.S.C. 1320d-2(b))) based on the input of 
     the National Committee on Vital and Health Statistics. The 
     Secretary may do so on an interim final basis and such rule 
     shall be effective not later than October 1, 2012.
       (2) Electronic funds transfer.--The Secretary shall 
     promulgate a final rule to establish a standard for 
     electronic funds transfers (as described in section 
     1173(a)(2)(J) of the Social Security Act, as added by 
     subsection (b)(2)(A)). The Secretary may do so on an interim 
     final basis and shall adopt such standard not later than 
     January 1, 2012, in a manner ensuring that such standard is 
     effective not later than January 1, 2014.
       (3) Health claims attachments.--The Secretary shall 
     promulgate a final rule to establish a transaction standard 
     and a single set of associated operating rules for health 
     claims attachments (as described in section 1173(a)(2)(B) of 
     the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B))) that is 
     consistent with the X12 Version 5010 transaction standards. 
     The Secretary may do so on an interim final basis and shall 
     adopt a transaction standard and a single set of associated 
     operating rules not later than January 1, 2014, in a manner 
     ensuring that such standard is effective not later than 
     January 1, 2016.
       (d) Expansion of Electronic Transactions in Medicare.--
     Section 1862(a) of the Social Security Act (42 U.S.C. 
     1395y(a)) is amended--
       (1) in paragraph (23), by striking the ``or'' at the end;
       (2) in paragraph (24), by striking the period and inserting 
     ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) not later than January 1, 2014, for which the 
     payment is other than by electronic funds transfer (EFT) or 
     an electronic remittance in a form as specified in ASC X12 
     835 Health Care Payment and Remittance Advice or subsequent 
     standard.''.

     SEC. 1105. EFFECTIVE DATE.

       This subtitle shall take effect on the date of enactment of 
     this Act.

    Subtitle C--Quality Health Insurance Coverage for All Americans

                PART I--HEALTH INSURANCE MARKET REFORMS

     SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.

       Part A of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg et seq.), as amended by section 1001, is further 
     amended--
       (1) by striking the heading for subpart 1 and inserting the 
     following:

                     ``Subpart I--General Reform'';

       (2)(A) in section 2701 (42 U.S.C. 300gg), by striking the 
     section heading and subsection (a) and inserting the 
     following:

     ``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS 
                   OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not impose any preexisting condition 
     exclusion with respect to such plan or coverage.''; and
       (B) by transferring such section (as amended by 
     subparagraph (A)) so as to appear after the section 2703 
     added by paragraph (4);
       (3)(A) in section 2702 (42 U.S.C. 300gg-1)--
       (i) by striking the section heading and all that follows 
     through subsection (a);
       (ii) in subsection (b)--
       (I) by striking ``health insurance issuer offering health 
     insurance coverage in connection with a group health plan'' 
     each place that such appears and inserting ``health insurance 
     issuer offering group or individual health insurance 
     coverage''; and
       (II) in paragraph (2)(A)--

       (aa) by inserting ``or individual'' after ``employer''; and
       (bb) by inserting ``or individual health coverage, as the 
     case may be'' before the semicolon; and

       (iii) in subsection (e)--
       (I) by striking ``(a)(1)(F)'' and inserting ``(a)(6)'';
       (II) by striking ``2701'' and inserting ``2704''; and
       (III) by striking ``2721(a)'' and inserting ``2735(a)''; 
     and
       (B) by transferring such section (as amended by 
     subparagraph (A)) to appear after section 2705(a) as added by 
     paragraph (4); and
       (4) by inserting after the subpart heading (as added by 
     paragraph (1)) the following:

     ``SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.

       ``(a) Prohibiting Discriminatory Premium Rates.--
       ``(1) In general.--With respect to the premium rate charged 
     by a health insurance issuer for health insurance coverage 
     offered in the individual or small group market--
       ``(A) such rate shall vary with respect to the particular 
     plan or coverage involved only by--
       ``(i) whether such plan or coverage covers an individual or 
     family;
       ``(ii) rating area, as established in accordance with 
     paragraph (2);
       ``(iii) age, except that such rate shall not vary by more 
     than 3 to 1 for adults (consistent with section 2707(c)); and
       ``(iv) tobacco use, except that such rate shall not vary by 
     more than 1.5 to 1; and
       ``(B) such rate shall not vary with respect to the 
     particular plan or coverage involved by any other factor not 
     described in subparagraph (A).
       ``(2) Rating area.--
       ``(A) In general.--Each State shall establish 1 or more 
     rating areas within that State for purposes of applying the 
     requirements of this title.
       ``(B) Secretarial review.--The Secretary shall review the 
     rating areas established by each State under subparagraph (A) 
     to ensure the adequacy of such areas for purposes of carrying 
     out the requirements of this title. If the Secretary 
     determines a State's rating areas are not adequate, or that a 
     State does not establish such areas, the Secretary may 
     establish rating areas for that State.
       ``(3) Permissible age bands.--The Secretary, in 
     consultation with the National Association of Insurance 
     Commissioners, shall define the permissible age bands for 
     rating purposes under paragraph (1)(A)(iii).
       ``(4) Application of variations based on age or tobacco 
     use.--With respect to family coverage under a group health 
     plan or health insurance coverage, the rating variations 
     permitted under clauses (iii) and (iv) of paragraph (1)(A) 
     shall be applied based on the portion of the premium that is 
     attributable to each family member covered under the plan or 
     coverage.
       ``(5) Special rule for large group market.--If a State 
     permits health insurance issuers that offer coverage in the 
     large group market in the State to offer such coverage 
     through the State Exchange (as provided for under section 
     1312(f)(2)(B) of the Patient Protection and Affordable Care 
     Act), the provisions of this subsection shall apply to all 
     coverage offered in such market in the State.

[[Page 4214]]



     ``SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.

       ``(a) Guaranteed Issuance of Coverage in the Individual and 
     Group Market.--Subject to subsections (b) through (e), each 
     health insurance issuer that offers health insurance coverage 
     in the individual or group market in a State must accept 
     every employer and individual in the State that applies for 
     such coverage.
       ``(b) Enrollment.--
       ``(1) Restriction.--A health insurance issuer described in 
     subsection (a) may restrict enrollment in coverage described 
     in such subsection to open or special enrollment periods.
       ``(2) Establishment.--A health insurance issuer described 
     in subsection (a) shall, in accordance with the regulations 
     promulgated under paragraph (3), establish special enrollment 
     periods for qualifying events (under section 603 of the 
     Employee Retirement Income Security Act of 1974).
       ``(3) Regulations.--The Secretary shall promulgate 
     regulations with respect to enrollment periods under 
     paragraphs (1) and (2).

     ``SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.

       ``(a) In General.--Except as provided in this section, if a 
     health insurance issuer offers health insurance coverage in 
     the individual or group market, the issuer must renew or 
     continue in force such coverage at the option of the plan 
     sponsor or the individual, as applicable.

     ``SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL 
                   PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH 
                   STATUS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not establish rules for eligibility 
     (including continued eligibility) of any individual to enroll 
     under the terms of the plan or coverage based on any of the 
     following health status-related factors in relation to the 
     individual or a dependent of the individual:
       ``(1) Health status.
       ``(2) Medical condition (including both physical and mental 
     illnesses).
       ``(3) Claims experience.
       ``(4) Receipt of health care.
       ``(5) Medical history.
       ``(6) Genetic information.
       ``(7) Evidence of insurability (including conditions 
     arising out of acts of domestic violence).
       ``(8) Disability.
       ``(9) Any other health status-related factor determined 
     appropriate by the Secretary.
       ``(j) Programs of Health Promotion or Disease Prevention.--
       ``(1) General provisions.--
       ``(A) General rule.--For purposes of subsection (b)(2)(B), 
     a program of health promotion or disease prevention (referred 
     to in this subsection as a `wellness program') shall be a 
     program offered by an employer that is designed to promote 
     health or prevent disease that meets the applicable 
     requirements of this subsection.
       ``(B) No conditions based on health status factor.--If none 
     of the conditions for obtaining a premium discount or rebate 
     or other reward for participation in a wellness program is 
     based on an individual satisfying a standard that is related 
     to a health status factor, such wellness program shall not 
     violate this section if participation in the program is made 
     available to all similarly situated individuals and the 
     requirements of paragraph (2) are complied with.
       ``(C) Conditions based on health status factor.--If any of 
     the conditions for obtaining a premium discount or rebate or 
     other reward for participation in a wellness program is based 
     on an individual satisfying a standard that is related to a 
     health status factor, such wellness program shall not violate 
     this section if the requirements of paragraph (3) are 
     complied with.
       ``(2) Wellness programs not subject to requirements.--If 
     none of the conditions for obtaining a premium discount or 
     rebate or other reward under a wellness program as described 
     in paragraph (1)(B) are based on an individual satisfying a 
     standard that is related to a health status factor (or if 
     such a wellness program does not provide such a reward), the 
     wellness program shall not violate this section if 
     participation in the program is made available to all 
     similarly situated individuals. The following programs shall 
     not have to comply with the requirements of paragraph (3) if 
     participation in the program is made available to all 
     similarly situated individuals:
       ``(A) A program that reimburses all or part of the cost for 
     memberships in a fitness center.
       ``(B) A diagnostic testing program that provides a reward 
     for participation and does not base any part of the reward on 
     outcomes.
       ``(C) A program that encourages preventive care related to 
     a health condition through the waiver of the copayment or 
     deductible requirement under group health plan for the costs 
     of certain items or services related to a health condition 
     (such as prenatal care or well-baby visits).
       ``(D) A program that reimburses individuals for the costs 
     of smoking cessation programs without regard to whether the 
     individual quits smoking.
       ``(E) A program that provides a reward to individuals for 
     attending a periodic health education seminar.
       ``(3) Wellness programs subject to requirements.--If any of 
     the conditions for obtaining a premium discount, rebate, or 
     reward under a wellness program as described in paragraph 
     (1)(C) is based on an individual satisfying a standard that 
     is related to a health status factor, the wellness program 
     shall not violate this section if the following requirements 
     are complied with:
       ``(A) The reward for the wellness program, together with 
     the reward for other wellness programs with respect to the 
     plan that requires satisfaction of a standard related to a 
     health status factor, shall not exceed 30 percent of the cost 
     of employee-only coverage under the plan. If, in addition to 
     employees or individuals, any class of dependents (such as 
     spouses or spouses and dependent children) may participate 
     fully in the wellness program, such reward shall not exceed 
     30 percent of the cost of the coverage in which an employee 
     or individual and any dependents are enrolled. For purposes 
     of this paragraph, the cost of coverage shall be determined 
     based on the total amount of employer and employee 
     contributions for the benefit package under which the 
     employee is (or the employee and any dependents are) 
     receiving coverage. A reward may be in the form of a discount 
     or rebate of a premium or contribution, a waiver of all or 
     part of a cost-sharing mechanism (such as deductibles, 
     copayments, or coinsurance), the absence of a surcharge, or 
     the value of a benefit that would otherwise not be provided 
     under the plan. The Secretaries of Labor, Health and Human 
     Services, and the Treasury may increase the reward available 
     under this subparagraph to up to 50 percent of the cost of 
     coverage if the Secretaries determine that such an increase 
     is appropriate.
       ``(B) The wellness program shall be reasonably designed to 
     promote health or prevent disease. A program complies with 
     the preceding sentence if the program has a reasonable chance 
     of improving the health of, or preventing disease in, 
     participating individuals and it is not overly burdensome, is 
     not a subterfuge for discriminating based on a health status 
     factor, and is not highly suspect in the method chosen to 
     promote health or prevent disease.
       ``(C) The plan shall give individuals eligible for the 
     program the opportunity to qualify for the reward under the 
     program at least once each year.
       ``(D) The full reward under the wellness program shall be 
     made available to all similarly situated individuals. For 
     such purpose, among other things:
       ``(i) The reward is not available to all similarly situated 
     individuals for a period unless the wellness program allows--

       ``(I) for a reasonable alternative standard (or waiver of 
     the otherwise applicable standard) for obtaining the reward 
     for any individual for whom, for that period, it is 
     unreasonably difficult due to a medical condition to satisfy 
     the otherwise applicable standard; and
       ``(II) for a reasonable alternative standard (or waiver of 
     the otherwise applicable standard) for obtaining the reward 
     for any individual for whom, for that period, it is medically 
     inadvisable to attempt to satisfy the otherwise applicable 
     standard.

       ``(ii) If reasonable under the circumstances, the plan or 
     issuer may seek verification, such as a statement from an 
     individual's physician, that a health status factor makes it 
     unreasonably difficult or medically inadvisable for the 
     individual to satisfy or attempt to satisfy the otherwise 
     applicable standard.
       ``(E) The plan or issuer involved shall disclose in all 
     plan materials describing the terms of the wellness program 
     the availability of a reasonable alternative standard (or the 
     possibility of waiver of the otherwise applicable standard) 
     required under subparagraph (D). If plan materials disclose 
     that such a program is available, without describing its 
     terms, the disclosure under this subparagraph shall not be 
     required.
       ``(k) Existing Programs.--Nothing in this section shall 
     prohibit a program of health promotion or disease prevention 
     that was established prior to the date of enactment of this 
     section and applied with all applicable regulations, and that 
     is operating on such date, from continuing to be carried out 
     for as long as such regulations remain in effect.
       ``(l) Wellness Program Demonstration Project.--
       ``(1) In general.--Not later than July 1, 2014, the 
     Secretary, in consultation with the Secretary of the Treasury 
     and the Secretary of Labor, shall establish a 10-State 
     demonstration project under which participating States shall 
     apply the provisions of subsection (j) to programs of health 
     promotion offered by a health insurance issuer that offers 
     health insurance coverage in the individual market in such 
     State.
       ``(2) Expansion of demonstration project.--If the 
     Secretary, in consultation with the Secretary of the Treasury 
     and the Secretary of Labor, determines that the demonstration 
     project described in paragraph (1) is effective, such 
     Secretaries may, beginning on July 1, 2017 expand such 
     demonstration project to include additional participating 
     States.
       ``(3) Requirements.--
       ``(A) Maintenance of coverage.--The Secretary, in 
     consultation with the Secretary of the Treasury and the 
     Secretary of Labor, shall not approve the participation of a 
     State in the demonstration project under this section unless 
     the Secretaries determine that the State's project is 
     designed in a manner that--
       ``(i) will not result in any decrease in coverage; and
       ``(ii) will not increase the cost to the Federal Government 
     in providing credits under section 36B of the Internal 
     Revenue Code of 1986 or cost-sharing assistance under section 
     1402 of the Patient Protection and Affordable Care Act.
       ``(B) Other requirements.--States that participate in the 
     demonstration project under this subsection--
       ``(i) may permit premium discounts or rebates or the 
     modification of otherwise applicable copayments or 
     deductibles for adherence to, or

[[Page 4215]]

     participation in, a reasonably designed program of health 
     promotion and disease prevention;
       ``(ii) shall ensure that requirements of consumer 
     protection are met in programs of health promotion in the 
     individual market;
       ``(iii) shall require verification from health insurance 
     issuers that offer health insurance coverage in the 
     individual market of such State that premium discounts--

       ``(I) do not create undue burdens for individuals insured 
     in the individual market;
       ``(II) do not lead to cost shifting; and
       ``(III) are not a subterfuge for discrimination;

       ``(iv) shall ensure that consumer data is protected in 
     accordance with the requirements of section 264(c) of the 
     Health Insurance Portability and Accountability Act of 1996 
     (42 U.S.C. 1320d-2 note); and
       ``(v) shall ensure and demonstrate to the satisfaction of 
     the Secretary that the discounts or other rewards provided 
     under the project reflect the expected level of participation 
     in the wellness program involved and the anticipated effect 
     the program will have on utilization or medical claim costs.
       ``(m) Report.--
       ``(1) In general.--Not later than 3 years after the date of 
     enactment of the Patient Protection and Affordable Care Act, 
     the Secretary, in consultation with the Secretary of the 
     Treasury and the Secretary of Labor, shall submit a report to 
     the appropriate committees of Congress concerning--
       ``(A) the effectiveness of wellness programs (as defined in 
     subsection (j)) in promoting health and preventing disease;
       ``(B) the impact of such wellness programs on the access to 
     care and affordability of coverage for participants and non-
     participants of such programs;
       ``(C) the impact of premium-based and cost-sharing 
     incentives on participant behavior and the role of such 
     programs in changing behavior; and
       ``(D) the effectiveness of different types of rewards.
       ``(2) Data collection.--In preparing the report described 
     in paragraph (1), the Secretaries shall gather relevant 
     information from employers who provide employees with access 
     to wellness programs, including State and Federal agencies.
       ``(n) Regulations.--Nothing in this section shall be 
     construed as prohibiting the Secretaries of Labor, Health and 
     Human Services, or the Treasury from promulgating regulations 
     in connection with this section.

     ``SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

       ``(a) Providers.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage shall not discriminate with respect to 
     participation under the plan or coverage against any health 
     care provider who is acting within the scope of that 
     provider's license or certification under applicable State 
     law. This section shall not require that a group health plan 
     or health insurance issuer contract with any health care 
     provider willing to abide by the terms and conditions for 
     participation established by the plan or issuer. Nothing in 
     this section shall be construed as preventing a group health 
     plan, a health insurance issuer, or the Secretary from 
     establishing varying reimbursement rates based on quality or 
     performance measures.
       ``(b) Individuals.--The provisions of section 1558 of the 
     Patient Protection and Affordable Care Act (relating to non-
     discrimination) shall apply with respect to a group health 
     plan or health insurance issuer offering group or individual 
     health insurance coverage.

     ``SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE.

       ``(a) Coverage for Essential Health Benefits Package.--A 
     health insurance issuer that offers health insurance coverage 
     in the individual or small group market shall ensure that 
     such coverage includes the essential health benefits package 
     required under section 1302(a) of the Patient Protection and 
     Affordable Care Act.
       ``(b) Cost-sharing Under Group Health Plans.--A group 
     health plan shall ensure that any annual cost-sharing imposed 
     under the plan does not exceed the limitations provided for 
     under paragraphs (1) and (2) of section 1302(c).
       ``(c) Child-only Plans.--If a health insurance issuer 
     offers health insurance coverage in any level of coverage 
     specified under section 1302(d) of the Patient Protection and 
     Affordable Care Act, the issuer shall also offer such 
     coverage in that level as a plan in which the only enrollees 
     are individuals who, as of the beginning of a plan year, have 
     not attained the age of 21.
       ``(d) Dental Only.--This section shall not apply to a plan 
     described in section 1302(d)(2)(B)(ii)(I).

     ``SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.

       ``A group health plan and a health insurance issuer 
     offering group or individual health insurance coverage shall 
     not apply any waiting period (as defined in section 
     2704(b)(4)) that exceeds 90 days.''.

                       PART II--OTHER PROVISIONS

     SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING 
                   COVERAGE.

       (a) No Changes to Existing Coverage.--
       (1) In general.--Nothing in this Act (or an amendment made 
     by this Act) shall be construed to require that an individual 
     terminate coverage under a group health plan or health 
     insurance coverage in which such individual was enrolled on 
     the date of enactment of this Act.
       (2) Continuation of coverage.--With respect to a group 
     health plan or health insurance coverage in which an 
     individual was enrolled on the date of enactment of this Act, 
     this subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply to such plan or coverage, 
     regardless of whether the individual renews such coverage 
     after such date of enactment.
       (b) Allowance for Family Members To Join Current 
     Coverage.--With respect to a group health plan or health 
     insurance coverage in which an individual was enrolled on the 
     date of enactment of this Act and which is renewed after such 
     date, family members of such individual shall be permitted to 
     enroll in such plan or coverage if such enrollment is 
     permitted under the terms of the plan in effect as of such 
     date of enactment.
       (c) Allowance for New Employees To Join Current Plan.--A 
     group health plan that provides coverage on the date of 
     enactment of this Act may provide for the enrolling of new 
     employees (and their families) in such plan, and this 
     subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply with respect to such plan and such 
     new employees (and their families).
       (d) Effect on Collective Bargaining Agreements.--In the 
     case of health insurance coverage maintained pursuant to one 
     or more collective bargaining agreements between employee 
     representatives and one or more employers that was ratified 
     before the date of enactment of this Act, the provisions of 
     this subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply until the date on which the last 
     of the collective bargaining agreements relating to the 
     coverage terminates. Any coverage amendment made pursuant to 
     a collective bargaining agreement relating to the coverage 
     which amends the coverage solely to conform to any 
     requirement added by this subtitle or subtitle A (or 
     amendments) shall not be treated as a termination of such 
     collective bargaining agreement.
       (e) Definition.--In this title, the term ``grandfathered 
     health plan'' means any group health plan or health insurance 
     coverage to which this section applies.

     SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH 
                   INSURANCE ISSUERS AND GROUP HEALTH PLANS.

       Any standard or requirement adopted by a State pursuant to 
     this title, or any amendment made by this title, shall be 
     applied uniformly to all health plans in each insurance 
     market to which the standard and requirements apply. The 
     preceding sentence shall also apply to a State standard or 
     requirement relating to the standard or requirement required 
     by this title (or any such amendment) that is not the same as 
     the standard or requirement but that is not preempted under 
     section 1321(d).

     SEC. 1253. EFFECTIVE DATES.

       This subtitle (and the amendments made by this subtitle) 
     shall become effective for plan years beginning on or after 
     January 1, 2014.

        Subtitle D--Available Coverage Choices for All Americans

            PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS

     SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.

       (a) Qualified Health Plan.--In this title:
       (1) In general.--The term ``qualified health plan'' means a 
     health plan that--
       (A) has in effect a certification (which may include a seal 
     or other indication of approval) that such plan meets the 
     criteria for certification described in section 1311(c) 
     issued or recognized by each Exchange through which such plan 
     is offered;
       (B) provides the essential health benefits package 
     described in section 1302(a); and
       (C) is offered by a health insurance issuer that--
       (i) is licensed and in good standing to offer health 
     insurance coverage in each State in which such issuer offers 
     health insurance coverage under this title;
       (ii) agrees to offer at least one qualified health plan in 
     the silver level and at least one plan in the gold level in 
     each such Exchange;
       (iii) agrees to charge the same premium rate for each 
     qualified health plan of the issuer without regard to whether 
     the plan is offered through an Exchange or whether the plan 
     is offered directly from the issuer or through an agent; and
       (iv) complies with the regulations developed by the 
     Secretary under section 1311(d) and such other requirements 
     as an applicable Exchange may establish.
       (2) Inclusion of co-op plans and community health insurance 
     option.--Any reference in this title to a qualified health 
     plan shall be deemed to include a qualified health plan 
     offered through the CO-OP program under section 1322 or a 
     community health insurance option under section 1323, unless 
     specifically provided for otherwise.
       (b) Terms Relating to Health Plans.--In this title:
       (1) Health plan.--
       (A) In general.--The term ``health plan'' means health 
     insurance coverage and a group health plan.
       (B) Exception for self-insured plans and mewas.--Except to 
     the extent specifically provided by this title, the term 
     ``health plan'' shall not include a group health plan or 
     multiple employer welfare arrangement to the extent the plan 
     or arrangement is not subject to State insurance regulation 
     under section 514 of the Employee Retirement Income Security 
     Act of 1974.
       (2) Health insurance coverage and issuer.--The terms 
     ``health insurance coverage'' and ``health insurance issuer'' 
     have the meanings given such terms by section 2791(b) of the 
     Public Health Service Act.

[[Page 4216]]

       (3) Group health plan.--The term ``group health plan'' has 
     the meaning given such term by section 2791(a) of the Public 
     Health Service Act.

     SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.

       (a) Essential Health Benefits Package.--In this title, the 
     term ``essential health benefits package'' means, with 
     respect to any health plan, coverage that--
       (1) provides for the essential health benefits defined by 
     the Secretary under subsection (b);
       (2) limits cost-sharing for such coverage in accordance 
     with subsection (c); and
       (3) subject to subsection (e), provides either the bronze, 
     silver, gold, or platinum level of coverage described in 
     subsection (d).
       (b) Essential Health Benefits.--
       (1) In general.--Subject to paragraph (2), the Secretary 
     shall define the essential health benefits, except that such 
     benefits shall include at least the following general 
     categories and the items and services covered within the 
     categories:
       (A) Ambulatory patient services.
       (B) Emergency services.
       (C) Hospitalization.
       (D) Maternity and newborn care.
       (E) Mental health and substance use disorder services, 
     including behavioral health treatment.
       (F) Prescription drugs.
       (G) Rehabilitative and habilitative services and devices.
       (H) Laboratory services.
       (I) Preventive and wellness services and chronic disease 
     management.
       (J) Pediatric services, including oral and vision care.
       (2) Limitation.--
       (A) In general.--The Secretary shall ensure that the scope 
     of the essential health benefits under paragraph (1) is equal 
     to the scope of benefits provided under a typical employer 
     plan, as determined by the Secretary. To inform this 
     determination, the Secretary of Labor shall conduct a survey 
     of employer-sponsored coverage to determine the benefits 
     typically covered by employers, including multiemployer 
     plans, and provide a report on such survey to the Secretary.
       (B) Certification.--In defining the essential health 
     benefits described in paragraph (1), and in revising the 
     benefits under paragraph (4)(H), the Secretary shall submit a 
     report to the appropriate committees of Congress containing a 
     certification from the Chief Actuary of the Centers for 
     Medicare & Medicaid Services that such essential health 
     benefits meet the limitation described in paragraph (2).
       (3) Notice and hearing.--In defining the essential health 
     benefits described in paragraph (1), and in revising the 
     benefits under paragraph (4)(H), the Secretary shall provide 
     notice and an opportunity for public comment.
       (4) Required elements for consideration.--In defining the 
     essential health benefits under paragraph (1), the Secretary 
     shall--
       (A) ensure that such essential health benefits reflect an 
     appropriate balance among the categories described in such 
     subsection, so that benefits are not unduly weighted toward 
     any category;
       (B) not make coverage decisions, determine reimbursement 
     rates, establish incentive programs, or design benefits in 
     ways that discriminate against individuals because of their 
     age, disability, or expected length of life;
       (C) take into account the health care needs of diverse 
     segments of the population, including women, children, 
     persons with disabilities, and other groups;
       (D) ensure that health benefits established as essential 
     not be subject to denial to individuals against their wishes 
     on the basis of the individuals' age or expected length of 
     life or of the individuals' present or predicted disability, 
     degree of medical dependency, or quality of life;
       (E) provide that a qualified health plan shall not be 
     treated as providing coverage for the essential health 
     benefits described in paragraph (1) unless the plan provides 
     that--
       (i) coverage for emergency department services will be 
     provided without imposing any requirement under the plan for 
     prior authorization of services or any limitation on coverage 
     where the provider of services does not have a contractual 
     relationship with the plan for the providing of services that 
     is more restrictive than the requirements or limitations that 
     apply to emergency department services received from 
     providers who do have such a contractual relationship with 
     the plan; and
       (ii) if such services are provided out-of-network, the 
     cost-sharing requirement (expressed as a copayment amount or 
     coinsurance rate) is the same requirement that would apply if 
     such services were provided in-network;
       (F) provide that if a plan described in section 
     1311(b)(2)(B)(ii) (relating to stand-alone dental benefits 
     plans) is offered through an Exchange, another health plan 
     offered through such Exchange shall not fail to be treated as 
     a qualified health plan solely because the plan does not 
     offer coverage of benefits offered through the stand-alone 
     plan that are otherwise required under paragraph (1)(J); and
       (G) periodically review the essential health benefits under 
     paragraph (1), and provide a report to Congress and the 
     public that contains--
       (i) an assessment of whether enrollees are facing any 
     difficulty accessing needed services for reasons of coverage 
     or cost;
       (ii) an assessment of whether the essential health benefits 
     needs to be modified or updated to account for changes in 
     medical evidence or scientific advancement;
       (iii) information on how the essential health benefits will 
     be modified to address any such gaps in access or changes in 
     the evidence base;
       (iv) an assessment of the potential of additional or 
     expanded benefits to increase costs and the interactions 
     between the addition or expansion of benefits and reductions 
     in existing benefits to meet actuarial limitations described 
     in paragraph (2); and
       (H) periodically update the essential health benefits under 
     paragraph (1) to address any gaps in access to coverage or 
     changes in the evidence base the Secretary identifies in the 
     review conducted under subparagraph (G).
       (5) Rule of construction.--Nothing in this title shall be 
     construed to prohibit a health plan from providing benefits 
     in excess of the essential health benefits described in this 
     subsection.
       (c) Requirements Relating to Cost-Sharing.--
       (1) Annual limitation on cost-sharing.--
       (A) 2014.--The cost-sharing incurred under a health plan 
     with respect to self-only coverage or coverage other than 
     self-only coverage for a plan year beginning in 2014 shall 
     not exceed the dollar amounts in effect under section 
     223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for 
     self-only and family coverage, respectively, for taxable 
     years beginning in 2014.
       (B) 2015 and later.--In the case of any plan year beginning 
     in a calendar year after 2014, the limitation under this 
     paragraph shall--
       (i) in the case of self-only coverage, be equal to the 
     dollar amount under subparagraph (A) for self-only coverage 
     for plan years beginning in 2014, increased by an amount 
     equal to the product of that amount and the premium 
     adjustment percentage under paragraph (4) for the calendar 
     year; and
       (ii) in the case of other coverage, twice the amount in 
     effect under clause (i).
     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       (2) Annual limitation on deductibles for employer-sponsored 
     plans.--
       (A) In general.--In the case of a health plan offered in 
     the small group market, the deductible under the plan shall 
     not exceed--
       (i) $2,000 in the case of a plan covering a single 
     individual; and
       (ii) $4,000 in the case of any other plan.

     The amounts under clauses (i) and (ii) may be increased by 
     the maximum amount of reimbursement which is reasonably 
     available to a participant under a flexible spending 
     arrangement described in section 106(c)(2) of the Internal 
     Revenue Code of 1986 (determined without regard to any salary 
     reduction arrangement).
       (B) Indexing of limits.--In the case of any plan year 
     beginning in a calendar year after 2014--
       (i) the dollar amount under subparagraph (A)(i) shall be 
     increased by an amount equal to the product of that amount 
     and the premium adjustment percentage under paragraph (4) for 
     the calendar year; and
       (ii) the dollar amount under subparagraph (A)(ii) shall be 
     increased to an amount equal to twice the amount in effect 
     under subparagraph (A)(i) for plan years beginning in the 
     calendar year, determined after application of clause (i).

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       (C) Actuarial value.--The limitation under this paragraph 
     shall be applied in such a manner so as to not affect the 
     actuarial value of any health plan, including a plan in the 
     bronze level.
       (D) Coordination with preventive limits.--Nothing in this 
     paragraph shall be construed to allow a plan to have a 
     deductible under the plan apply to benefits described in 
     section 2713 of the Public Health Service Act.
       (3) Cost-sharing.--In this title--
       (A) In general.--The term ``cost-sharing'' includes--
       (i) deductibles, coinsurance, copayments, or similar 
     charges; and
       (ii) any other expenditure required of an insured 
     individual which is a qualified medical expense (within the 
     meaning of section 223(d)(2) of the Internal Revenue Code of 
     1986) with respect to essential health benefits covered under 
     the plan.
       (B) Exceptions.--Such term does not include premiums, 
     balance billing amounts for non-network providers, or 
     spending for non-covered services.
       (4) Premium adjustment percentage.--For purposes of 
     paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment 
     percentage for any calendar year is the percentage (if any) 
     by which the average per capita premium for health insurance 
     coverage in the United States for the preceding calendar year 
     (as estimated by the Secretary no later than October 1 of 
     such preceding calendar year) exceeds such average per capita 
     premium for 2013 (as determined by the Secretary).
       (d) Levels of Coverage.--
       (1) Levels of coverage defined.--The levels of coverage 
     described in this subsection are as follows:
       (A) Bronze level.--A plan in the bronze level shall provide 
     a level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 60 percent of the full 
     actuarial value of the benefits provided under the plan.
       (B) Silver level.--A plan in the silver level shall provide 
     a level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 70 percent of the full 
     actuarial value of the benefits provided under the plan.
       (C) Gold level.--A plan in the gold level shall provide a 
     level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 80 percent of the full 
     actuarial value of the benefits provided under the plan.

[[Page 4217]]

       (D) Platinum level.--A plan in the platinum level shall 
     provide a level of coverage that is designed to provide 
     benefits that are actuarially equivalent to 90 percent of the 
     full actuarial value of the benefits provided under the plan.
       (2) Actuarial value.--
       (A) In general.--Under regulations issued by the Secretary, 
     the level of coverage of a plan shall be determined on the 
     basis that the essential health benefits described in 
     subsection (b) shall be provided to a standard population 
     (and without regard to the population the plan may actually 
     provide benefits to).
       (B) Employer contributions.--The Secretary may issue 
     regulations under which employer contributions to a health 
     savings account (within the meaning of section 223 of the 
     Internal Revenue Code of 1986) may be taken into account in 
     determining the level of coverage for a plan of the employer.
       (C) Application.--In determining under this title, the 
     Public Health Service Act, or the Internal Revenue Code of 
     1986 the percentage of the total allowed costs of benefits 
     provided under a group health plan or health insurance 
     coverage that are provided by such plan or coverage, the 
     rules contained in the regulations under this paragraph shall 
     apply.
       (3) Allowable variance.--The Secretary shall develop 
     guidelines to provide for a de minimis variation in the 
     actuarial valuations used in determining the level of 
     coverage of a plan to account for differences in actuarial 
     estimates.
       (4) Plan reference.--In this title, any reference to a 
     bronze, silver, gold, or platinum plan shall be treated as a 
     reference to a qualified health plan providing a bronze, 
     silver, gold, or platinum level of coverage, as the case may 
     be.
       (e) Catastrophic Plan.--
       (1) In general.--A health plan not providing a bronze, 
     silver, gold, or platinum level of coverage shall be treated 
     as meeting the requirements of subsection (d) with respect to 
     any plan year if--
       (A) the only individuals who are eligible to enroll in the 
     plan are individuals described in paragraph (2); and
       (B) the plan provides--
       (i) except as provided in clause (ii), the essential health 
     benefits determined under subsection (b), except that the 
     plan provides no benefits for any plan year until the 
     individual has incurred cost-sharing expenses in an amount 
     equal to the annual limitation in effect under subsection 
     (c)(1) for the plan year (except as provided for in section 
     2713); and
       (ii) coverage for at least three primary care visits.
       (2) Individuals eligible for enrollment.--An individual is 
     described in this paragraph for any plan year if the 
     individual--
       (A) has not attained the age of 30 before the beginning of 
     the plan year; or
       (B) has a certification in effect for any plan year under 
     this title that the individual is exempt from the requirement 
     under section 5000A of the Internal Revenue Code of 1986 by 
     reason of--
       (i) section 5000A(e)(1) of such Code (relating to 
     individuals without affordable coverage); or
       (ii) section 5000A(e)(5) of such Code (relating to 
     individuals with hardships).
       (3) Restriction to individual market.--If a health 
     insurance issuer offers a health plan described in this 
     subsection, the issuer may only offer the plan in the 
     individual market.
       (f) Child-only Plans.--If a qualified health plan is 
     offered through the Exchange in any level of coverage 
     specified under subsection (d), the issuer shall also offer 
     that plan through the Exchange in that level as a plan in 
     which the only enrollees are individuals who, as of the 
     beginning of a plan year, have not attained the age of 21, 
     and such plan shall be treated as a qualified health plan.

     SEC. 1303. SPECIAL RULES.

       (a) Special Rules Relating to Coverage of Abortion 
     Services.--
       (1) Voluntary choice of coverage of abortion services.--
       (A) In general.--Notwithstanding any other provision of 
     this title (or any amendment made by this title), and subject 
     to subparagraphs (C) and (D)--
       (i) nothing in this title (or any amendment made by this 
     title), shall be construed to require a qualified health plan 
     to provide coverage of services described in subparagraph 
     (B)(i) or (B)(ii) as part of its essential health benefits 
     for any plan year; and
       (ii) the issuer of a qualified health plan shall determine 
     whether or not the plan provides coverage of services 
     described in subparagraph (B)(i) or (B)(ii) as part of such 
     benefits for the plan year.
       (B) Abortion services.--
       (i) Abortions for which public funding is prohibited.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is not permitted, based on the 
     law as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       (ii) Abortions for which public funding is allowed.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is permitted, based on the law 
     as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       (C) Prohibition on federal funds for abortion services in 
     community health insurance option.--
       (i) Determination by secretary.--The Secretary may not 
     determine, in accordance with subparagraph (A)(ii), that the 
     community health insurance option established under section 
     1323 shall provide coverage of services described in 
     subparagraph (B)(i) as part of benefits for the plan year 
     unless the Secretary--

       (I) assures compliance with the requirements of paragraph 
     (2);
       (II) assures, in accordance with applicable provisions of 
     generally accepted accounting requirements, circulars on 
     funds management of the Office of Management and Budget, and 
     guidance on accounting of the Government Accountability 
     Office, that no Federal funds are used for such coverage; and
       (III) notwithstanding section 1323(e)(1)(C) or any other 
     provision of this title, takes all necessary steps to assure 
     that the United States does not bear the insurance risk for a 
     community health insurance option's coverage of services 
     described in subparagraph (B)(i).

       (ii) State requirement.--If a State requires, in addition 
     to the essential health benefits required under section 
     1323(b)(3) (A), coverage of services described in 
     subparagraph (B)(i) for enrollees of a community health 
     insurance option offered in such State, the State shall 
     assure that no funds flowing through or from the community 
     health insurance option, and no other Federal funds, pay or 
     defray the cost of providing coverage of services described 
     in subparagraph (B)(i). The United States shall not bear the 
     insurance risk for a State's required coverage of services 
     described in subparagraph (B)(i).
       (iii) Exceptions.--Nothing in this subparagraph shall apply 
     to coverage of services described in subparagraph (B)(ii) by 
     the community health insurance option. Services described in 
     subparagraph (B)(ii) shall be covered to the same extent as 
     such services are covered under title XIX of the Social 
     Security Act.
       (D) Assured availability of varied coverage through 
     exchanges.--
       (i) In general.--The Secretary shall assure that with 
     respect to qualified health plans offered in any Exchange 
     established pursuant to this title--

       (I) there is at least one such plan that provides coverage 
     of services described in clauses (i) and (ii) of subparagraph 
     (B); and
       (II) there is at least one such plan that does not provide 
     coverage of services described in subparagraph (B)(i).

       (ii) Special rules.--For purposes of clause (i)--

       (I) a plan shall be treated as described in clause (i)(II) 
     if the plan does not provide coverage of services described 
     in either subparagraph (B)(i) or (B)(ii); and
       (II) if a State has one Exchange covering more than 1 
     insurance market, the Secretary shall meet the requirements 
     of clause (i) separately with respect to each such market.

       (2) Prohibition on the use of federal funds.--
       (A) In general.--If a qualified health plan provides 
     coverage of services described in paragraph (1)(B)(i), the 
     issuer of the plan shall not use any amount attributable to 
     any of the following for purposes of paying for such 
     services:
       (i) The credit under section 36B of the Internal Revenue 
     Code of 1986 (and the amount (if any) of the advance payment 
     of the credit under section 1412 of the Patient Protection 
     and Affordable Care Act).
       (ii) Any cost-sharing reduction under section 1402 of 
     thePatient Protection and Affordable Care Act (and the amount 
     (if any) of the advance payment of the reduction under 
     section 1412 of the Patient Protection and Affordable Care 
     Act).
       (B) Segregation of funds.--In the case of a plan to which 
     subparagraph (A) applies, the issuer of the plan shall, out 
     of amounts not described in subparagraph (A), segregate an 
     amount equal to the actuarial amounts determined under 
     subparagraph (C) for all enrollees from the amounts described 
     in subparagraph (A).
       (C) Actuarial value of optional service coverage.--
       (i) In general.--The Secretary shall estimate the basic per 
     enrollee, per month cost, determined on an average actuarial 
     basis, for including coverage under a qualified health plan 
     of the services described in paragraph (1)(B)(i).
       (ii) Considerations.--In making such estimate, the 
     Secretary--

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

       (3) Provider conscience protections.--No individual health 
     care provider or health care facility may be discriminated 
     against because of a willingness or an unwillingness, if 
     doing so is contrary to the religious or moral beliefs of the 
     provider or facility, to provide, pay for, provide coverage 
     of, or refer for abortions.
       (b) Application of State and Federal Laws Regarding 
     Abortion.--
       (1) No preemption of state laws regarding abortion.--
     Nothing in this Act shall be construed to preempt or 
     otherwise have any effect on State laws regarding the 
     prohibition of (or requirement of) coverage, funding, or 
     procedural requirements on abortions, including parental 
     notification or consent for the performance of an abortion on 
     a minor.
       (2) No effect on federal laws regarding abortion.--

[[Page 4218]]

       (A) In general.--Nothing in this Act shall be construed to 
     have any effect on Federal laws regarding--
       (i) conscience protection;
       (ii) willingness or refusal to provide abortion; and
       (iii) discrimination on the basis of the willingness or 
     refusal to provide, pay for, cover, or refer for abortion or 
     to provide or participate in training to provide abortion.
       (3) No effect on federal civil rights law.--Nothing in this 
     subsection shall alter the rights and obligations of 
     employees and employers under title VII of the Civil Rights 
     Act of 1964.
       (c) Application of Emergency Services Laws.--Nothing in 
     this Act shall be construed to relieve any health care 
     provider from providing emergency services as required by 
     State or Federal law, including section 1867 of the Social 
     Security Act (popularly known as ``EMTALA'').

     SEC. 1304. RELATED DEFINITIONS.

       (a) Definitions Relating to Markets.--In this title:
       (1) Group market.--The term ``group market'' means the 
     health insurance market under which individuals obtain health 
     insurance coverage (directly or through any arrangement) on 
     behalf of themselves (and their dependents) through a group 
     health plan maintained by an employer.
       (2) Individual market.--The term ``individual market'' 
     means the market for health insurance coverage offered to 
     individuals other than in connection with a group health 
     plan.
       (3) Large and small group markets.--The terms ``large group 
     market'' and ``small group market'' mean the health insurance 
     market under which individuals obtain health insurance 
     coverage (directly or through any arrangement) on behalf of 
     themselves (and their dependents) through a group health plan 
     maintained by a large employer (as defined in subsection 
     (b)(1)) or by a small employer (as defined in subsection 
     (b)(2)), respectively.
       (b) Employers.--In this title:
       (1) Large employer.--The term ``large employer'' means, in 
     connection with a group health plan with respect to a 
     calendar year and a plan year, an employer who employed an 
     average of at least 101 employees on business days during the 
     preceding calendar year and who employs at least 1 employee 
     on the first day of the plan year.
       (2) Small employer.--The term ``small employer'' means, in 
     connection with a group health plan with respect to a 
     calendar year and a plan year, an employer who employed an 
     average of at least 1 but not more than 100 employees on 
     business days during the preceding calendar year and who 
     employs at least 1 employee on the first day of the plan 
     year.
       (3) State option to treat 50 employees as small.--In the 
     case of plan years beginning before January 1, 2016, a State 
     may elect to apply this subsection by substituting ``51 
     employees'' for ``101 employees'' in paragraph (1) and by 
     substituting ``50 employees'' for ``100 employees'' in 
     paragraph (2).
       (4) Rules for determining employer size.--For purposes of 
     this subsection--
       (A) Application of aggregation rule for employers.--All 
     persons treated as a single employer under subsection (b), 
     (c), (m), or (o) of section 414 of the Internal Revenue Code 
     of 1986 shall be treated as 1 employer.
       (B) Employers not in existence in preceding year.--In the 
     case of an employer which was not in existence throughout the 
     preceding calendar year, the determination of whether such 
     employer is a small or large employer shall be based on the 
     average number of employees that it is reasonably expected 
     such employer will employ on business days in the current 
     calendar year.
       (C) Predecessors.--Any reference in this subsection to an 
     employer shall include a reference to any predecessor of such 
     employer.
       (D) Continuation of participation for growing small 
     employers.--If--
       (i) a qualified employer that is a small employer makes 
     enrollment in qualified health plans offered in the small 
     group market available to its employees through an Exchange; 
     and
       (ii) the employer ceases to be a small employer by reason 
     of an increase in the number of employees of such employer;
     the employer shall continue to be treated as a small employer 
     for purposes of this subtitle for the period beginning with 
     the increase and ending with the first day on which the 
     employer does not make such enrollment available to its 
     employees.
       (c) Secretary.--In this title, the term ``Secretary'' means 
     the Secretary of Health and Human Services.
       (d) State.--In this title, the term ``State'' means each of 
     the 50 States and the District of Columbia.

  PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 
                           BENEFIT EXCHANGES

     SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.

       (a) Assistance to States to Establish American Health 
     Benefit Exchanges.--
       (1) Planning and establishment grants.--There shall be 
     appropriated to the Secretary, out of any moneys in the 
     Treasury not otherwise appropriated, an amount necessary to 
     enable the Secretary to make awards, not later than 1 year 
     after the date of enactment of this Act, to States in the 
     amount specified in paragraph (2) for the uses described in 
     paragraph (3).
       (2) Amount specified.--For each fiscal year, the Secretary 
     shall determine the total amount that the Secretary will make 
     available to each State for grants under this subsection.
       (3) Use of funds.--A State shall use amounts awarded under 
     this subsection for activities (including planning 
     activities) related to establishing an American Health 
     Benefit Exchange, as described in subsection (b).
       (4) Renewability of grant.--
       (A) In general.--Subject to subsection (d)(4), the 
     Secretary may renew a grant awarded under paragraph (1) if 
     the State recipient of such grant--
       (i) is making progress, as determined by the Secretary, 
     toward--

       (I) establishing an Exchange; and
       (II) implementing the reforms described in subtitles A and 
     C (and the amendments made by such subtitles); and

       (ii) is meeting such other benchmarks as the Secretary may 
     establish.
       (B) Limitation.--No grant shall be awarded under this 
     subsection after January 1, 2015.
       (5) Technical assistance to facilitate participation in 
     shop exchanges.--The Secretary shall provide technical 
     assistance to States to facilitate the participation of 
     qualified small businesses in such States in SHOP Exchanges.
       (b) American Health Benefit Exchanges.--
       (1) In general.--Each State shall, not later than January 
     1, 2014, establish an American Health Benefit Exchange 
     (referred to in this title as an ``Exchange'') for the State 
     that--
       (A) facilitates the purchase of qualified health plans;
       (B) provides for the establishment of a Small Business 
     Health Options Program (in this title referred to as a ``SHOP 
     Exchange'') that is designed to assist qualified employers in 
     the State who are small employers in facilitating the 
     enrollment of their employees in qualified health plans 
     offered in the small group market in the State; and
       (C) meets the requirements of subsection (d).
       (2) Merger of individual and shop exchanges.--A State may 
     elect to provide only one Exchange in the State for providing 
     both Exchange and SHOP Exchange services to both qualified 
     individuals and qualified small employers, but only if the 
     Exchange has adequate resources to assist such individuals 
     and employers.
       (c) Responsibilities of the Secretary.--
       (1) In general.--The Secretary shall, by regulation, 
     establish criteria for the certification of health plans as 
     qualified health plans. Such criteria shall require that, to 
     be certified, a plan shall, at a minimum--
       (A) meet marketing requirements, and not employ marketing 
     practices or benefit designs that have the effect of 
     discouraging the enrollment in such plan by individuals with 
     significant health needs;
       (B) ensure a sufficient choice of providers (in a manner 
     consistent with applicable network adequacy provisions under 
     section 2702(c) of the Public Health Service Act), and 
     provide information to enrollees and prospective enrollees on 
     the availability of in-network and out-of-network providers;
       (C) include within health insurance plan networks those 
     essential community providers, where available, that serve 
     predominately low-income, medically-underserved individuals, 
     such as health care providers defined in section 340B(a)(4) 
     of the Public Health Service Act and providers described in 
     section 1927(c)(1)(D)(i)(IV) of the Social Security Act as 
     set forth by section 221 of Public Law 111-8, except that 
     nothing in this subparagraph shall be construed to require 
     any health plan to provide coverage for any specific medical 
     procedure;
       (D)(i) be accredited with respect to local performance on 
     clinical quality measures such as the Healthcare 
     Effectiveness Data and Information Set, patient experience 
     ratings on a standardized Consumer Assessment of Healthcare 
     Providers and Systems survey, as well as consumer access, 
     utilization management, quality assurance, provider 
     credentialing, complaints and appeals, network adequacy and 
     access, and patient information programs by any entity 
     recognized by the Secretary for the accreditation of health 
     insurance issuers or plans (so long as any such entity has 
     transparent and rigorous methodological and scoring 
     criteria); or
       (ii) receive such accreditation within a period established 
     by an Exchange for such accreditation that is applicable to 
     all qualified health plans;
       (E) implement a quality improvement strategy described in 
     subsection (g)(1);
       (F) utilize a uniform enrollment form that qualified 
     individuals and qualified employers may use (either 
     electronically or on paper) in enrolling in qualified health 
     plans offered through such Exchange, and that takes into 
     account criteria that the National Association of Insurance 
     Commissioners develops and submits to the Secretary;
       (G) utilize the standard format established for presenting 
     health benefits plan options; and
       (H) provide information to enrollees and prospective 
     enrollees, and to each Exchange in which the plan is offered, 
     on any quality measures for health plan performance endorsed 
     under section 399JJ of the Public Health Service Act, as 
     applicable.
       (2) Rule of construction.--Nothing in paragraph (1)(C) 
     shall be construed to require a qualified health plan to 
     contract with a provider described in such paragraph if such 
     provider refuses to accept the generally applicable payment 
     rates of such plan.
       (3) Rating system.--The Secretary shall develop a rating 
     system that would rate qualified health plans offered through 
     an Exchange in

[[Page 4219]]

     each benefits level on the basis of the relative quality and 
     price. The Exchange shall include the quality rating in the 
     information provided to individuals and employers through the 
     Internet portal established under paragraph (4).
       (4) Enrollee satisfaction system.--The Secretary shall 
     develop an enrollee satisfaction survey system that would 
     evaluate the level of enrollee satisfaction with qualified 
     health plans offered through an Exchange, for each such 
     qualified health plan that had more than 500 enrollees in the 
     previous year. The Exchange shall include enrollee 
     satisfaction information in the information provided to 
     individuals and employers through the Internet portal 
     established under paragraph (5) in a manner that allows 
     individuals to easily compare enrollee satisfaction levels 
     between comparable plans.
       (5) Internet portals.--The Secretary shall--
       (A) continue to operate, maintain, and update the Internet 
     portal developed under section 1103(a) and to assist States 
     in developing and maintaining their own such portal; and
       (B) make available for use by Exchanges a model template 
     for an Internet portal that may be used to direct qualified 
     individuals and qualified employers to qualified health 
     plans, to assist such individuals and employers in 
     determining whether they are eligible to participate in an 
     Exchange or eligible for a premium tax credit or cost-sharing 
     reduction, and to present standardized information (including 
     quality ratings) regarding qualified health plans offered 
     through an Exchange to assist consumers in making easy health 
     insurance choices.

     Such template shall include, with respect to each qualified 
     health plan offered through the Exchange in each rating area, 
     access to the uniform outline of coverage the plan is 
     required to provide under section 2716 of the Public Health 
     Service Act and to a copy of the plan's written policy.
       (6) Enrollment periods.--The Secretary shall require an 
     Exchange to provide for--
       (A) an initial open enrollment, as determined by the 
     Secretary (such determination to be made not later than July 
     1, 2012);
       (B) annual open enrollment periods, as determined by the 
     Secretary for calendar years after the initial enrollment 
     period;
       (C) special enrollment periods specified in section 9801 of 
     the Internal Revenue Code of 1986 and other special 
     enrollment periods under circumstances similar to such 
     periods under part D of title XVIII of the Social Security 
     Act; and
       (D) special monthly enrollment periods for Indians (as 
     defined in section 4 of the Indian Health Care Improvement 
     Act).
       (d) Requirements.--
       (1) In general.--An Exchange shall be a governmental agency 
     or nonprofit entity that is established by a State.
       (2) Offering of coverage.--
       (A) In general.--An Exchange shall make available qualified 
     health plans to qualified individuals and qualified 
     employers.
       (B) Limitation.--
       (i) In general.--An Exchange may not make available any 
     health plan that is not a qualified health plan.
       (ii) Offering of stand-alone dental benefits.--Each 
     Exchange within a State shall allow an issuer of a plan that 
     only provides limited scope dental benefits meeting the 
     requirements of section 9832(c)(2)(A) of the Internal Revenue 
     Code of 1986 to offer the plan through the Exchange (either 
     separately or in conjunction with a qualified health plan) if 
     the plan provides pediatric dental benefits meeting the 
     requirements of section 1302(b)(1)(J)).
       (3) Rules relating to additional required benefits.--
       (A) In general.--Except as provided in subparagraph (B), an 
     Exchange may make available a qualified health plan 
     notwithstanding any provision of law that may require 
     benefits other than the essential health benefits specified 
     under section 1302(b).
       (B) States may require additional benefits.--
       (i) In general.--Subject to the requirements of clause 
     (ii), a State may require that a qualified health plan 
     offered in such State offer benefits in addition to the 
     essential health benefits specified under section 1302(b).
       (ii) State must assume cost.--A State shall make payments 
     to or on behalf of an individual eligible for the premium tax 
     credit under section 36B of the Internal Revenue Code of 1986 
     and any cost-sharing reduction under section 1402 to defray 
     the cost to the individual of any additional benefits 
     described in clause (i) which are not eligible for such 
     credit or reduction under section 36B(b)(3)(D) of such Code 
     and section 1402(c)(4).
       (4) Functions.--An Exchange shall, at a minimum--
       (A) implement procedures for the certification, 
     recertification, and decertification, consistent with 
     guidelines developed by the Secretary under subsection (c), 
     of health plans as qualified health plans;
       (B) provide for the operation of a toll-free telephone 
     hotline to respond to requests for assistance;
       (C) maintain an Internet website through which enrollees 
     and prospective enrollees of qualified health plans may 
     obtain standardized comparative information on such plans;
       (D) assign a rating to each qualified health plan offered 
     through such Exchange in accordance with the criteria 
     developed by the Secretary under subsection (c)(3);
       (E) utilize a standardized format for presenting health 
     benefits plan options in the Exchange, including the use of 
     the uniform outline of coverage established under section 
     2715 of the Public Health Service Act;
       (F) in accordance with section 1413, inform individuals of 
     eligibility requirements for the medicaid program under title 
     XIX of the Social Security Act, the CHIP program under title 
     XXI of such Act, or any applicable State or local public 
     program and if through screening of the application by the 
     Exchange, the Exchange determines that such individuals are 
     eligible for any such program, enroll such individuals in 
     such program;
       (G) establish and make available by electronic means a 
     calculator to determine the actual cost of coverage after the 
     application of any premium tax credit under section 36B of 
     the Internal Revenue Code of 1986 and any cost-sharing 
     reduction under section 1402;
       (H) subject to section 1411, grant a certification 
     attesting that, for purposes of the individual responsibility 
     penalty under section 5000A of the Internal Revenue Code of 
     1986, an individual is exempt from the individual requirement 
     or from the penalty imposed by such section because--
       (i) there is no affordable qualified health plan available 
     through the Exchange, or the individual's employer, covering 
     the individual; or
       (ii) the individual meets the requirements for any other 
     such exemption from the individual responsibility requirement 
     or penalty;
       (I) transfer to the Secretary of the Treasury--
       (i) a list of the individuals who are issued a 
     certification under subparagraph (H), including the name and 
     taxpayer identification number of each individual;
       (ii) the name and taxpayer identification number of each 
     individual who was an employee of an employer but who was 
     determined to be eligible for the premium tax credit under 
     section 36B of the Internal Revenue Code of 1986 because--

       (I) the employer did not provide minimum essential 
     coverage; or
       (II) the employer provided such minimum essential coverage 
     but it was determined under section 36B(c)(2)(C) of such Code 
     to either be unaffordable to the employee or not provide the 
     required minimum actuarial value; and

       (iii) the name and taxpayer identification number of each 
     individual who notifies the Exchange under section 1411(b)(4) 
     that they have changed employers and of each individual who 
     ceases coverage under a qualified health plan during a plan 
     year (and the effective date of such cessation);
       (J) provide to each employer the name of each employee of 
     the employer described in subparagraph (I)(ii) who ceases 
     coverage under a qualified health plan during a plan year 
     (and the effective date of such cessation); and
       (K) establish the Navigator program described in subsection 
     (i).
       (5) Funding limitations.--
       (A) No federal funds for continued operations.--In 
     establishing an Exchange under this section, the State shall 
     ensure that such Exchange is self-sustaining beginning on 
     January 1, 2015, including allowing the Exchange to charge 
     assessments or user fees to participating health insurance 
     issuers, or to otherwise generate funding, to support its 
     operations.
       (B) Prohibiting wasteful use of funds.--In carrying out 
     activities under this subsection, an Exchange shall not 
     utilize any funds intended for the administrative and 
     operational expenses of the Exchange for staff retreats, 
     promotional giveaways, excessive executive compensation, or 
     promotion of Federal or State legislative and regulatory 
     modifications.
       (6) Consultation.--An Exchange shall consult with 
     stakeholders relevant to carrying out the activities under 
     this section, including--
       (A) health care consumers who are enrollees in qualified 
     health plans;
       (B) individuals and entities with experience in 
     facilitating enrollment in qualified health plans;
       (C) representatives of small businesses and self-employed 
     individuals;
       (D) State Medicaid offices; and
       (E) advocates for enrolling hard to reach populations.
       (7) Publication of costs.--An Exchange shall publish the 
     average costs of licensing, regulatory fees, and any other 
     payments required by the Exchange, and the administrative 
     costs of such Exchange, on an Internet website to educate 
     consumers on such costs. Such information shall also include 
     monies lost to waste, fraud, and abuse.
       (e) Certification.--
       (1) In general.--An Exchange may certify a health plan as a 
     qualified health plan if--
       (A) such health plan meets the requirements for 
     certification as promulgated by the Secretary under 
     subsection (c)(1); and
       (B) the Exchange determines that making available such 
     health plan through such Exchange is in the interests of 
     qualified individuals and qualified employers in the State or 
     States in which such Exchange operates, except that the 
     Exchange may not exclude a health plan--
       (i) on the basis that such plan is a fee-for-service plan;
       (ii) through the imposition of premium price controls; or
       (iii) on the basis that the plan provides treatments 
     necessary to prevent patients' deaths in circumstances the 
     Exchange determines are inappropriate or too costly.
       (2) Premium considerations.--The Exchange shall require 
     health plans seeking certification as qualified health plans 
     to submit a justification for any premium increase prior to 
     implementation of the increase. Such plans shall

[[Page 4220]]

     prominently post such information on their websites. The 
     Exchange may take this information, and the information and 
     the recommendations provided to the Exchange by the State 
     under section 2794(b)(1) of the Public Health Service Act 
     (relating to patterns or practices of excessive or 
     unjustified premium increases), into consideration when 
     determining whether to make such health plan available 
     through the Exchange. The Exchange shall take into account 
     any excess of premium growth outside the Exchange as compared 
     to the rate of such growth inside the Exchange, including 
     information reported by the States.
       (f) Flexibility.--
       (1) Regional or other interstate exchanges.--An Exchange 
     may operate in more than one State if--
       (A) each State in which such Exchange operates permits such 
     operation; and
       (B) the Secretary approves such regional or interstate 
     Exchange.
       (2) Subsidiary exchanges.--A State may establish one or 
     more subsidiary Exchanges if--
       (A) each such Exchange serves a geographically distinct 
     area; and
       (B) the area served by each such Exchange is at least as 
     large as a rating area described in section 2701(a) of the 
     Public Health Service Act.
       (3) Authority to contract.--
       (A) In general.--A State may elect to authorize an Exchange 
     established by the State under this section to enter into an 
     agreement with an eligible entity to carry out 1 or more 
     responsibilities of the Exchange.
       (B) Eligible entity.--In this paragraph, the term 
     ``eligible entity'' means--
       (i) a person--

       (I) incorporated under, and subject to the laws of, 1 or 
     more States;
       (II) that has demonstrated experience on a State or 
     regional basis in the individual and small group health 
     insurance markets and in benefits coverage; and
       (III) that is not a health insurance issuer or that is 
     treated under subsection (a) or (b) of section 52 of the 
     Internal Revenue Code of 1986 as a member of the same 
     controlled group of corporations (or under common control 
     with) as a health insurance issuer; or

       (ii) the State medicaid agency under title XIX of the 
     Social Security Act.
       (g) Rewarding Quality Through Market-Based Incentives.--
       (1) Strategy described.--A strategy described in this 
     paragraph is a payment structure that provides increased 
     reimbursement or other incentives for--
       (A) improving health outcomes through the implementation of 
     activities that shall include quality reporting, effective 
     case management, care coordination, chronic disease 
     management, medication and care compliance initiatives, 
     including through the use of the medical home model, for 
     treatment or services under the plan or coverage;
       (B) the implementation of activities to prevent hospital 
     readmissions through a comprehensive program for hospital 
     discharge that includes patient-centered education and 
     counseling, comprehensive discharge planning, and post 
     discharge reinforcement by an appropriate health care 
     professional;
       (C) the implementation of activities to improve patient 
     safety and reduce medical errors through the appropriate use 
     of best clinical practices, evidence based medicine, and 
     health information technology under the plan or coverage; and
       (D) the implementation of wellness and health promotion 
     activities.
       (2) Guidelines.--The Secretary, in consultation with 
     experts in health care quality and stakeholders, shall 
     develop guidelines concerning the matters described in 
     paragraph (1).
       (3) Requirements.--The guidelines developed under paragraph 
     (2) shall require the periodic reporting to the applicable 
     Exchange of the activities that a qualified health plan has 
     conducted to implement a strategy described in paragraph (1).
       (h) Quality Improvement.--
       (1) Enhancing patient safety.--Beginning on January 1, 
     2015, a qualified health plan may contract with--
       (A) a hospital with greater than 50 beds only if such 
     hospital--
       (i) utilizes a patient safety evaluation system as 
     described in part C of title IX of the Public Health Service 
     Act; and
       (ii) implements a mechanism to ensure that each patient 
     receives a comprehensive program for hospital discharge that 
     includes patient-centered education and counseling, 
     comprehensive discharge planning, and post discharge 
     reinforcement by an appropriate health care professional; or
       (B) a health care provider only if such provider implements 
     such mechanisms to improve health care quality as the 
     Secretary may by regulation require.
       (2) Exceptions.--The Secretary may establish reasonable 
     exceptions to the requirements described in paragraph (1).
       (3) Adjustment.--The Secretary may by regulation adjust the 
     number of beds described in paragraph (1)(A).
       (i) Navigators.--
       (1) In general.--An Exchange shall establish a program 
     under which it awards grants to entities described in 
     paragraph (2) to carry out the duties described in paragraph 
     (3).
       (2) Eligibility.--
       (A) In general.--To be eligible to receive a grant under 
     paragraph (1), an entity shall demonstrate to the Exchange 
     involved that the entity has existing relationships, or could 
     readily establish relationships, with employers and 
     employees, consumers (including uninsured and underinsured 
     consumers), or self-employed individuals likely to be 
     qualified to enroll in a qualified health plan.
       (B) Types.--Entities described in subparagraph (A) may 
     include trade, industry, and professional associations, 
     commercial fishing industry organizations, ranching and 
     farming organizations, community and consumer-focused 
     nonprofit groups, chambers of commerce, unions, small 
     business development centers, other licensed insurance agents 
     and brokers, and other entities that--
       (i) are capable of carrying out the duties described in 
     paragraph (3);
       (ii) meet the standards described in paragraph (4); and
       (iii) provide information consistent with the standards 
     developed under paragraph (5).
       (3) Duties.--An entity that serves as a navigator under a 
     grant under this subsection shall--
       (A) conduct public education activities to raise awareness 
     of the availability of qualified health plans;
       (B) distribute fair and impartial information concerning 
     enrollment in qualified health plans, and the availability of 
     premium tax credits under section 36B of the Internal Revenue 
     Code of 1986 and cost-sharing reductions under section 1402;
       (C) facilitate enrollment in qualified health plans;
       (D) provide referrals to any applicable office of health 
     insurance consumer assistance or health insurance ombudsman 
     established under section 2793 of the Public Health Service 
     Act, or any other appropriate State agency or agencies, for 
     any enrollee with a grievance, complaint, or question 
     regarding their health plan, coverage, or a determination 
     under such plan or coverage; and
       (E) provide information in a manner that is culturally and 
     linguistically appropriate to the needs of the population 
     being served by the Exchange or Exchanges.
       (4) Standards.--
       (A) In general.--The Secretary shall establish standards 
     for navigators under this subsection, including provisions to 
     ensure that any private or public entity that is selected as 
     a navigator is qualified, and licensed if appropriate, to 
     engage in the navigator activities described in this 
     subsection and to avoid conflicts of interest. Under such 
     standards, a navigator shall not--
       (i) be a health insurance issuer; or
       (ii) receive any consideration directly or indirectly from 
     any health insurance issuer in connection with the enrollment 
     of any qualified individuals or employees of a qualified 
     employer in a qualified health plan.
       (5) Fair and impartial information and services.--The 
     Secretary, in collaboration with States, shall develop 
     standards to ensure that information made available by 
     navigators is fair, accurate, and impartial.
       (6) Funding.--Grants under this subsection shall be made 
     from the operational funds of the Exchange and not Federal 
     funds received by the State to establish the Exchange.
       (j) Applicability of Mental Health Parity.--Section 2726 of 
     the Public Health Service Act shall apply to qualified health 
     plans in the same manner and to the same extent as such 
     section applies to health insurance issuers and group health 
     plans.
       (k) Conflict.--An Exchange may not establish rules that 
     conflict with or prevent the application of regulations 
     promulgated by the Secretary under this subtitle.

     SEC. 1312. CONSUMER CHOICE.

       (a) Choice.--
       (1) Qualified individuals.--A qualified individual may 
     enroll in any qualified health plan available to such 
     individual.
       (2) Qualified employers.--
       (A) Employer may specify level.--A qualified employer may 
     provide support for coverage of employees under a qualified 
     health plan by selecting any level of coverage under section 
     1302(d) to be made available to employees through an 
     Exchange.
       (B) Employee may choose plans within a level.--Each 
     employee of a qualified employer that elects a level of 
     coverage under subparagraph (A) may choose to enroll in a 
     qualified health plan that offers coverage at that level.
       (b) Payment of Premiums by Qualified Individuals.--A 
     qualified individual enrolled in any qualified health plan 
     may pay any applicable premium owed by such individual to the 
     health insurance issuer issuing such qualified health plan.
       (c) Single Risk Pool.--
       (1) Individual market.--A health insurance issuer shall 
     consider all enrollees in all health plans (other than 
     grandfathered health plans) offered by such issuer in the 
     individual market, including those enrollees who do not 
     enroll in such plans through the Exchange, to be members of a 
     single risk pool.
       (2) Small group market.--A health insurance issuer shall 
     consider all enrollees in all health plans (other than 
     grandfathered health plans) offered by such issuer in the 
     small group market, including those enrollees who do not 
     enroll in such plans through the Exchange, to be members of a 
     single risk pool.
       (3) Merger of markets.--A State may require the individual 
     and small group insurance markets within a State to be merged 
     if the State determines appropriate.
       (4) State law.--A State law requiring grandfathered health 
     plans to be included in a pool described in paragraph (1) or 
     (2) shall not apply.

[[Page 4221]]

       (d) Empowering Consumer Choice.--
       (1) Continued operation of market outside exchanges.--
     Nothing in this title shall be construed to prohibit--
       (A) a health insurance issuer from offering outside of an 
     Exchange a health plan to a qualified individual or qualified 
     employer; and
       (B) a qualified individual from enrolling in, or a 
     qualified employer from selecting for its employees, a health 
     plan offered outside of an Exchange.
       (2) Continued operation of state benefit requirements.--
     Nothing in this title shall be construed to terminate, 
     abridge, or limit the operation of any requirement under 
     State law with respect to any policy or plan that is offered 
     outside of an Exchange to offer benefits.
       (3) Voluntary nature of an exchange.--
       (A) Choice to enroll or not to enroll.--Nothing in this 
     title shall be construed to restrict the choice of a 
     qualified individual to enroll or not to enroll in a 
     qualified health plan or to participate in an Exchange.
       (B) Prohibition against compelled enrollment.--Nothing in 
     this title shall be construed to compel an individual to 
     enroll in a qualified health plan or to participate in an 
     Exchange.
       (C) Individuals allowed to enroll in any plan.--A qualified 
     individual may enroll in any qualified health plan, except 
     that in the case of a catastrophic plan described in section 
     1302(e), a qualified individual may enroll in the plan only 
     if the individual is eligible to enroll in the plan under 
     section 1302(e)(2).
       (D) Members of congress in the exchange.--
       (i) Requirement.--Notwithstanding any other provision of 
     law, after the effective date of this subtitle, the only 
     health plans that the Federal Government may make available 
     to Members of Congress and congressional staff with respect 
     to their service as a Member of Congress or congressional 
     staff shall be health plans that are--

       (I) created under this Act (or an amendment made by this 
     Act); or
       (II) offered through an Exchange established under this Act 
     (or an amendment made by this Act).

       (ii) Definitions.--In this section:

       (I) Member of congress.--The term ``Member of Congress'' 
     means any member of the House of Representatives or the 
     Senate.
       (II) Congressional staff.--The term ``congressional staff'' 
     means all full-time and part-time employees employed by the 
     official office of a Member of Congress, whether in 
     Washington, DC or outside of Washington, DC.

       (4) No penalty for transferring to minimum essential 
     coverage outside exchange.--An Exchange, or a qualified 
     health plan offered through an Exchange, shall not impose any 
     penalty or other fee on an individual who cancels enrollment 
     in a plan because the individual becomes eligible for minimum 
     essential coverage (as defined in section 5000A(f) of the 
     Internal Revenue Code of 1986 without regard to paragraph 
     (1)(C) or (D) thereof) or such coverage becomes affordable 
     (within the meaning of section 36B(c)(2)(C) of such Code).
       (e) Enrollment Through Agents or Brokers.--The Secretary 
     shall establish procedures under which a State may allow 
     agents or brokers--
       (1) to enroll individuals in any qualified health plans in 
     the individual or small group market as soon as the plan is 
     offered through an Exchange in the State; and
       (2) to assist individuals in applying for premium tax 
     credits and cost-sharing reductions for plans sold through an 
     Exchange.

     Such procedures may include the establishment of rate 
     schedules for broker commissions paid by health benefits 
     plans offered through an exchange.
       (f) Qualified Individuals and Employers; Access Limited to 
     Citizens and Lawful Residents.--
       (1) Qualified individuals.--In this title:
       (A) In general.--The term ``qualified individual'' means, 
     with respect to an Exchange, an individual who--
       (i) is seeking to enroll in a qualified health plan in the 
     individual market offered through the Exchange; and
       (ii) resides in the State that established the Exchange 
     (except with respect to territorial agreements under section 
     1312(f)).
       (B) Incarcerated individuals excluded.--An individual shall 
     not be treated as a qualified individual if, at the time of 
     enrollment, the individual is incarcerated, other than 
     incarceration pending the disposition of charges.
       (2) Qualified employer.--In this title:
       (A) In general.--The term ``qualified employer'' means a 
     small employer that elects to make all full-time employees of 
     such employer eligible for 1 or more qualified health plans 
     offered in the small group market through an Exchange that 
     offers qualified health plans.
       (B) Extension to large groups.--
       (i) In general.--Beginning in 2017, each State may allow 
     issuers of health insurance coverage in the large group 
     market in the State to offer qualified health plans in such 
     market through an Exchange. Nothing in this subparagraph 
     shall be construed as requiring the issuer to offer such 
     plans through an Exchange.
       (ii) Large employers eligible.--If a State under clause (i) 
     allows issuers to offer qualified health plans in the large 
     group market through an Exchange, the term ``qualified 
     employer'' shall include a large employer that elects to make 
     all full-time employees of such employer eligible for 1 or 
     more qualified health plans offered in the large group market 
     through the Exchange.
       (3) Access limited to lawful residents.--If an individual 
     is not, or is not reasonably expected to be for the entire 
     period for which enrollment is sought, a citizen or national 
     of the United States or an alien lawfully present in the 
     United States, the individual shall not be treated as a 
     qualified individual and may not be covered under a qualified 
     health plan in the individual market that is offered through 
     an Exchange.

     SEC. 1313. FINANCIAL INTEGRITY.

       (a) Accounting for Expenditures.--
       (1) In general.--An Exchange shall keep an accurate 
     accounting of all activities, receipts, and expenditures and 
     shall annually submit to the Secretary a report concerning 
     such accountings.
       (2) Investigations.--The Secretary, in coordination with 
     the Inspector General of the Department of Health and Human 
     Services, may investigate the affairs of an Exchange, may 
     examine the properties and records of an Exchange, and may 
     require periodic reports in relation to activities undertaken 
     by an Exchange. An Exchange shall fully cooperate in any 
     investigation conducted under this paragraph.
       (3) Audits.--An Exchange shall be subject to annual audits 
     by the Secretary.
       (4) Pattern of abuse.--If the Secretary determines that an 
     Exchange or a State has engaged in serious misconduct with 
     respect to compliance with the requirements of, or carrying 
     out of activities required under, this title, the Secretary 
     may rescind from payments otherwise due to such State 
     involved under this or any other Act administered by the 
     Secretary an amount not to exceed 1 percent of such payments 
     per year until corrective actions are taken by the State that 
     are determined to be adequate by the Secretary.
       (5) Protections against fraud and abuse.--With respect to 
     activities carried out under this title, the Secretary shall 
     provide for the efficient and non-discriminatory 
     administration of Exchange activities and implement any 
     measure or procedure that--
       (A) the Secretary determines is appropriate to reduce fraud 
     and abuse in the administration of this title; and
       (B) the Secretary has authority to implement under this 
     title or any other Act.
       (6) Application of the false claims act.--
       (A) In general.--Payments made by, through, or in 
     connection with an Exchange are subject to the False Claims 
     Act (31 U.S.C. 3729 et seq.) if those payments include any 
     Federal funds. Compliance with the requirements of this Act 
     concerning eligibility for a health insurance issuer to 
     participate in the Exchange shall be a material condition of 
     an issuer's entitlement to receive payments, including 
     payments of premium tax credits and cost-sharing reductions, 
     through the Exchange.
       (B) Damages.--Notwithstanding paragraph (1) of section 
     3729(a) of title 31, United States Code, and subject to 
     paragraph (2) of such section, the civil penalty assessed 
     under the False Claims Act on any person found liable under 
     such Act as described in subparagraph (A) shall be increased 
     by not less than 3 times and not more than 6 times the amount 
     of damages which the Government sustains because of the act 
     of that person.
       (b) GAO Oversight.--Not later than 5 years after the first 
     date on which Exchanges are required to be operational under 
     this title, the Comptroller General shall conduct an ongoing 
     study of Exchange activities and the enrollees in qualified 
     health plans offered through Exchanges. Such study shall 
     review--
       (1) the operations and administration of Exchanges, 
     including surveys and reports of qualified health plans 
     offered through Exchanges and on the experience of such plans 
     (including data on enrollees in Exchanges and individuals 
     purchasing health insurance coverage outside of Exchanges), 
     the expenses of Exchanges, claims statistics relating to 
     qualified health plans, complaints data relating to such 
     plans, and the manner in which Exchanges meet their goals;
       (2) any significant observations regarding the utilization 
     and adoption of Exchanges;
       (3) where appropriate, recommendations for improvements in 
     the operations or policies of Exchanges; and
       (4) how many physicians, by area and specialty, are not 
     taking or accepting new patients enrolled in Federal 
     Government health care programs, and the adequacy of provider 
     networks of Federal Government health care programs.

           PART III--STATE FLEXIBILITY RELATING TO EXCHANGES

     SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF 
                   EXCHANGES AND RELATED REQUIREMENTS.

       (a) Establishment of Standards.--
       (1) In general.--The Secretary shall, as soon as 
     practicable after the date of enactment of this Act, issue 
     regulations setting standards for meeting the requirements 
     under this title, and the amendments made by this title, with 
     respect to--
       (A) the establishment and operation of Exchanges (including 
     SHOP Exchanges);
       (B) the offering of qualified health plans through such 
     Exchanges;
       (C) the establishment of the reinsurance and risk 
     adjustment programs under part V; and
       (D) such other requirements as the Secretary determines 
     appropriate.

     The preceding sentence shall not apply to standards for 
     requirements under subtitles A and C (and the amendments made 
     by such subtitles) for which the Secretary issues regulations 
     under the Public Health Service Act.
       (2) Consultation.--In issuing the regulations under 
     paragraph (1), the Secretary shall consult

[[Page 4222]]

     with the National Association of Insurance Commissioners and 
     its members and with health insurance issuers, consumer 
     organizations, and such other individuals as the Secretary 
     selects in a manner designed to ensure balanced 
     representation among interested parties.
       (b) State Action.--Each State that elects, at such time and 
     in such manner as the Secretary may prescribe, to apply the 
     requirements described in subsection (a) shall, not later 
     than January 1, 2014, adopt and have in effect--
       (1) the Federal standards established under subsection (a); 
     or
       (2) a State law or regulation that the Secretary determines 
     implements the standards within the State.
       (c) Failure To Establish Exchange or Implement 
     Requirements.--
       (1) In general.--If--
       (A) a State is not an electing State under subsection (b); 
     or
       (B) the Secretary determines, on or before January 1, 2013, 
     that an electing State--
       (i) will not have any required Exchange operational by 
     January 1, 2014; or
       (ii) has not taken the actions the Secretary determines 
     necessary to implement--

       (I) the other requirements set forth in the standards under 
     subsection (a); or
       (II) the requirements set forth in subtitles A and C and 
     the amendments made by such subtitles;

     the Secretary shall (directly or through agreement with a 
     not-for-profit entity) establish and operate such Exchange 
     within the State and the Secretary shall take such actions as 
     are necessary to implement such other requirements.
       (2) Enforcement authority.--The provisions of section 
     2736(b) of the Public Health Services Act shall apply to the 
     enforcement under paragraph (1) of requirements of subsection 
     (a)(1) (without regard to any limitation on the application 
     of those provisions to group health plans).
       (d) No Interference With State Regulatory Authority.--
     Nothing in this title shall be construed to preempt any State 
     law that does not prevent the application of the provisions 
     of this title.
       (e) Presumption for Certain State-Operated Exchanges.--
       (1) In general.--In the case of a State operating an 
     Exchange before January 1, 2010, and which has insured a 
     percentage of its population not less than the percentage of 
     the population projected to be covered nationally after the 
     implementation of this Act, that seeks to operate an Exchange 
     under this section, the Secretary shall presume that such 
     Exchange meets the standards under this section unless the 
     Secretary determines, after completion of the process 
     established under paragraph (2), that the Exchange does not 
     comply with such standards.
       (2) Process.--The Secretary shall establish a process to 
     work with a State described in paragraph (1) to provide 
     assistance necessary to assist the State's Exchange in coming 
     into compliance with the standards for approval under this 
     section.

     SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND 
                   OPERATION OF NONPROFIT, MEMBER-RUN HEALTH 
                   INSURANCE ISSUERS.

       (a) Establishment of Program.--
       (1) In general.--The Secretary shall establish a program to 
     carry out the purposes of this section to be known as the 
     Consumer Operated and Oriented Plan (CO-OP) program.
       (2) Purpose.--It is the purpose of the CO-OP program to 
     foster the creation of qualified nonprofit health insurance 
     issuers to offer qualified health plans in the individual and 
     small group markets in the States in which the issuers are 
     licensed to offer such plans.
       (b) Loans and Grants Under the CO-OP Program.--
       (1) In general.--The Secretary shall provide through the 
     CO-OP program for the awarding to persons applying to become 
     qualified nonprofit health insurance issuers of--
       (A) loans to provide assistance to such person in meeting 
     its start-up costs; and
       (B) grants to provide assistance to such person in meeting 
     any solvency requirements of States in which the person seeks 
     to be licensed to issue qualified health plans.
       (2) Requirements for awarding loans and grants.--
       (A) In general.--In awarding loans and grants under the CO-
     OP program, the Secretary shall--
       (i) take into account the recommendations of the advisory 
     board established under paragraph (3);
       (ii) give priority to applicants that will offer qualified 
     health plans on a Statewide basis, will utilize integrated 
     care models, and have significant private support; and
       (iii) ensure that there is sufficient funding to establish 
     at least 1 qualified nonprofit health insurance issuer in 
     each State, except that nothing in this clause shall prohibit 
     the Secretary from funding the establishment of multiple 
     qualified nonprofit health insurance issuers in any State if 
     the funding is sufficient to do so.
       (B) States without issuers in program.--If no health 
     insurance issuer applies to be a qualified nonprofit health 
     insurance issuer within a State, the Secretary may use 
     amounts appropriated under this section for the awarding of 
     grants to encourage the establishment of a qualified 
     nonprofit health insurance issuer within the State or the 
     expansion of a qualified nonprofit health insurance issuer 
     from another State to the State.
       (C) Agreement.--
       (i) In general.--The Secretary shall require any person 
     receiving a loan or grant under the CO-OP program to enter 
     into an agreement with the Secretary which requires such 
     person to meet (and to continue to meet)--

       (I) any requirement under this section for such person to 
     be treated as a qualified nonprofit health insurance issuer; 
     and
       (II) any requirements contained in the agreement for such 
     person to receive such loan or grant.

       (ii) Restrictions on use of federal funds.--The agreement 
     shall include a requirement that no portion of the funds made 
     available by any loan or grant under this section may be 
     used--

       (I) for carrying on propaganda, or otherwise attempting, to 
     influence legislation; or
       (II) for marketing.

     Nothing in this clause shall be construed to allow a person 
     to take any action prohibited by section 501(c)(29) of the 
     Internal Revenue Code of 1986.
       (iii) Failure to meet requirements.--If the Secretary 
     determines that a person has failed to meet any requirement 
     described in clause (i) or (ii) and has failed to correct 
     such failure within a reasonable period of time of when the 
     person first knows (or reasonably should have known) of such 
     failure, such person shall repay to the Secretary an amount 
     equal to the sum of--

       (I) 110 percent of the aggregate amount of loans and grants 
     received under this section; plus
       (II) interest on the aggregate amount of loans and grants 
     received under this section for the period the loans or 
     grants were outstanding.

     The Secretary shall notify the Secretary of the Treasury of 
     any determination under this section of a failure that 
     results in the termination of an issuer's tax-exempt status 
     under section 501(c)(29) of such Code.
       (D) Time for awarding loans and grants.--The Secretary 
     shall not later than July 1, 2013, award the loans and grants 
     under the CO-OP program and begin the distribution of amounts 
     awarded under such loans and grants.
       (3) Advisory board.--
       (A) In general.--The advisory board under this paragraph 
     shall consist of 15 members appointed by the Comptroller 
     General of the United States from among individuals with 
     qualifications described in section 1805(c)(2) of the Social 
     Security Act.
       (B) Rules relating to appointments.--
       (i) Standards.--Any individual appointed under subparagraph 
     (A) shall meet ethics and conflict of interest standards 
     protecting against insurance industry involvement and 
     interference.
       (ii) Original appointments.--The original appointment of 
     board members under subparagraph (A)(ii) shall be made no 
     later than 3 months after the date of enactment of this Act.
       (C) Vacancy.--Any vacancy on the advisory board shall be 
     filled in the same manner as the original appointment.
       (D) Pay and reimbursement.--
       (i) No compensation for members of advisory board.--Except 
     as provided in clause (ii), a member of the advisory board 
     may not receive pay, allowances, or benefits by reason of 
     their service on the board.
       (ii) Travel expenses.--Each member shall receive travel 
     expenses, including per diem in lieu of subsistence under 
     subchapter I of chapter 57 of title 5, United States Code.
       (E) Application of faca.--The Federal Advisory Committee 
     Act (5 U.S.C. App.) shall apply to the advisory board, except 
     that section 14 of such Act shall not apply.
       (F) Termination.--The advisory board shall terminate on the 
     earlier of the date that it completes its duties under this 
     section or December 31, 2015.
       (c) Qualified Nonprofit Health Insurance Issuer.--For 
     purposes of this section--
       (1) In general.--The term ``qualified nonprofit health 
     insurance issuer'' means a health insurance issuer that is an 
     organization--
       (A) that is organized under State law as a nonprofit, 
     member corporation;
       (B) substantially all of the activities of which consist of 
     the issuance of qualified health plans in the individual and 
     small group markets in each State in which it is licensed to 
     issue such plans; and
       (C) that meets the other requirements of this subsection.
       (2) Certain organizations prohibited.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer if--
       (A) the organization or a related entity (or any 
     predecessor of either) was a health insurance issuer on July 
     16, 2009; or
       (B) the organization is sponsored by a State or local 
     government, any political subdivision thereof, or any 
     instrumentality of such government or political subdivision.
       (3) Governance requirements.--An organization shall not be 
     treated as a qualified nonprofit health insurance issuer 
     unless--
       (A) the governance of the organization is subject to a 
     majority vote of its members;
       (B) its governing documents incorporate ethics and conflict 
     of interest standards protecting against insurance industry 
     involvement and interference; and
       (C) as provided in regulations promulgated by the 
     Secretary, the organization is required to operate with a 
     strong consumer focus, including timeliness, responsiveness, 
     and accountability to members.
       (4) Profits inure to benefit of members.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer unless

[[Page 4223]]

     any profits made by the organization are required to be used 
     to lower premiums, to improve benefits, or for other programs 
     intended to improve the quality of health care delivered to 
     its members.
       (5) Compliance with state insurance laws.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer unless the organization meets all the 
     requirements that other issuers of qualified health plans are 
     required to meet in any State where the issuer offers a 
     qualified health plan, including solvency and licensure 
     requirements, rules on payments to providers, and compliance 
     with network adequacy rules, rate and form filing rules, any 
     applicable State premium assessments and any other State law 
     described in section 1324(b).
       (6) Coordination with state insurance reforms.--An 
     organization shall not be treated as a qualified nonprofit 
     health insurance issuer unless the organization does not 
     offer a health plan in a State until that State has in effect 
     (or the Secretary has implemented for the State) the market 
     reforms required by part A of title XXVII of the Public 
     Health Service Act (as amended by subtitles A and C of this 
     Act).
       (d) Establishment of Private Purchasing Council.--
       (1) In general.--Qualified nonprofit health insurance 
     issuers participating in the CO-OP program under this section 
     may establish a private purchasing council to enter into 
     collective purchasing arrangements for items and services 
     that increase administrative and other cost efficiencies, 
     including claims administration, administrative services, 
     health information technology, and actuarial services.
       (2) Council may not set payment rates.--The private 
     purchasing council established under paragraph (1) shall not 
     set payment rates for health care facilities or providers 
     participating in health insurance coverage provided by 
     qualified nonprofit health insurance issuers.
       (3) Continued application of antitrust laws.--
       (A) In general.--Nothing in this section shall be construed 
     to limit the application of the antitrust laws to any private 
     purchasing council (whether or not established under this 
     subsection) or to any qualified nonprofit health insurance 
     issuer participating in such a council.
       (B) Antitrust laws.--For purposes of this subparagraph, the 
     term ``antitrust laws'' has the meaning given the term in 
     subsection (a) of the first section of the Clayton Act (15 
     U.S.C. 12(a)). Such term also includes section 5 of the 
     Federal Trade Commission Act (15 U.S.C. 45) to the extent 
     that such section 5 applies to unfair methods of competition.
       (e) Limitation on Participation.--No representative of any 
     Federal, State, or local government (or of any political 
     subdivision or instrumentality thereof), and no 
     representative of a person described in subsection (c)(2)(A), 
     may serve on the board of directors of a qualified nonprofit 
     health insurance issuer or with a private purchasing council 
     established under subsection (d).
       (f) Limitations on Secretary.--
       (1) In general.--The Secretary shall not--
       (A) participate in any negotiations between 1 or more 
     qualified nonprofit health insurance issuers (or a private 
     purchasing council established under subsection (d)) and any 
     health care facilities or providers, including any drug 
     manufacturer, pharmacy, or hospital; and
       (B) establish or maintain a price structure for 
     reimbursement of any health benefits covered by such issuers.
       (2) Competition.--Nothing in this section shall be 
     construed as authorizing the Secretary to interfere with the 
     competitive nature of providing health benefits through 
     qualified nonprofit health insurance issuers.
       (g) Appropriations.--There are hereby appropriated, out of 
     any funds in the Treasury not otherwise appropriated, 
     $6,000,000,000 to carry out this section.
       (h) Tax Exemption for Qualified Nonprofit Health Insurance 
     Issuer.--
       (1) In general.--Section 501(c) of the Internal Revenue 
     Code of 1986 (relating to list of exempt organizations) is 
     amended by adding at the end the following:
       ``(29) CO-OP health insurance issuers.--
       ``(A) In general.--A qualified nonprofit health insurance 
     issuer (within the meaning of section 1322 of the Patient 
     Protection and Affordable Care Act) which has received a loan 
     or grant under the CO-OP program under such section, but only 
     with respect to periods for which the issuer is in compliance 
     with the requirements of such section and any agreement with 
     respect to the loan or grant.
       ``(B) Conditions for exemption.--Subparagraph (A) shall 
     apply to an organization only if--
       ``(i) the organization has given notice to the Secretary, 
     in such manner as the Secretary may by regulations prescribe, 
     that it is applying for recognition of its status under this 
     paragraph,
       ``(ii) except as provided in section 1322(c)(4) of the 
     Patient Protection and Affordable Care Act, no part of the 
     net earnings of which inures to the benefit of any private 
     shareholder or individual,
       ``(iii) no substantial part of the activities of which is 
     carrying on propaganda, or otherwise attempting, to influence 
     legislation, and
       ``(iv) the organization does not participate in, or 
     intervene in (including the publishing or distributing of 
     statements), any political campaign on behalf of (or in 
     opposition to) any candidate for public office.''.
       (2) Additional reporting requirement.--Section 6033 of such 
     Code (relating to returns by exempt organizations) is amended 
     by redesignating subsection (m) as subsection (n) and by 
     inserting after subsection (l) the following:
       ``(m) Additional Information Required From CO-OP 
     Insurers.--An organization described in section 501(c)(29) 
     shall include on the return required under subsection (a) the 
     following information:
       ``(1) The amount of the reserves required by each State in 
     which the organization is licensed to issue qualified health 
     plans.
       ``(2) The amount of reserves on hand.''.
       (3) Application of tax on excess benefit transactions.--
     Section 4958(e)(1) of such Code (defining applicable tax-
     exempt organization) is amended by striking ``paragraph (3) 
     or (4)'' and inserting ``paragraph (3), (4), or (29)''.
       (i) GAO Study and Report.--
       (1) Study.--The Comptroller General of the General 
     Accountability Office shall conduct an ongoing study on 
     competition and market concentration in the health insurance 
     market in the United States after the implementation of the 
     reforms in such market under the provisions of, and the 
     amendments made by, this Act. Such study shall include an 
     analysis of new issuers of health insurance in such market.
       (2) Report.--The Comptroller General shall, not later than 
     December 31 of each even-numbered year (beginning with 2014), 
     report to the appropriate committees of the Congress the 
     results of the study conducted under paragraph (1), including 
     any recommendations for administrative or legislative changes 
     the Comptroller General determines necessary or appropriate 
     to increase competition in the health insurance market.

     SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.

       (a) Voluntary Nature.--
       (1) No requirement for health care providers to 
     participate.--Nothing in this section shall be construed to 
     require a health care provider to participate in a community 
     health insurance option, or to impose any penalty for non-
     participation.
       (2) No requirement for individuals to join.--Nothing in 
     this section shall be construed to require an individual to 
     participate in a community health insurance option, or to 
     impose any penalty for non-participation.
       (3) State opt out.--
       (A) In general.--A State may elect to prohibit Exchanges in 
     such State from offering a community health insurance option 
     if such State enacts a law to provide for such prohibition.
       (B) Termination of opt out.--A State may repeal a law 
     described in subparagraph (A) and provide for the offering of 
     such an option through the Exchange.
       (b) Establishment of Community Health Insurance Option.--
       (1) Establishment.--The Secretary shall establish a 
     community health insurance option to offer, through the 
     Exchanges established under this title (other than Exchanges 
     in States that elect to opt out as provided for in subsection 
     (a)(3)), health care coverage that provides value, choice, 
     competition, and stability of affordable, high quality 
     coverage throughout the United States.
       (2) Community health insurance option.--In this section, 
     the term ``community health insurance option'' means health 
     insurance coverage that--
       (A) except as specifically provided for in this section, 
     complies with the requirements for being a qualified health 
     plan;
       (B) provides high value for the premium charged;
       (C) reduces administrative costs and promotes 
     administrative simplification for beneficiaries;
       (D) promotes high quality clinical care;
       (E) provides high quality customer service to 
     beneficiaries;
       (F) offers a sufficient choice of providers; and
       (G) complies with State laws (if any), except as otherwise 
     provided for in this title, relating to the laws described in 
     section 1324(b).
       (3) Essential health benefits.--
       (A) General rule.--Except as provided in subparagraph (B), 
     a community health insurance option offered under this 
     section shall provide coverage only for the essential health 
     benefits described in section 1302(b).
       (B) States may offer additional benefits.--Nothing in this 
     section shall preclude a State from requiring that benefits 
     in addition to the essential health benefits required under 
     subparagraph (A) be provided to enrollees of a community 
     health insurance option offered in such State.
       (C) Credits.--
       (i) In general.--An individual enrolled in a community 
     health insurance option under this section shall be eligible 
     for credits under section 36B of the Internal Revenue Code of 
     1986 in the same manner as an individual who is enrolled in a 
     qualified health plan.
       (ii) No additional federal cost.--A requirement by a State 
     under subparagraph (B) that benefits in addition to the 
     essential health benefits required under subparagraph (A) be 
     provided to enrollees of a community health insurance option 
     shall not affect the amount of a premium tax credit provided 
     under section 36B of the Internal Revenue Code of 1986 with 
     respect to such plan.
       (D) State must assume cost.--A State shall make payments to 
     or on behalf of an eligible individual to defray the cost of 
     any additional benefits described in subparagraph (B).
       (E) Ensuring access to all services.--Nothing in this Act 
     shall prohibit an individual enrolled in a community health 
     insurance option from paying out-of-pocket the full cost of 
     any

[[Page 4224]]

     item or service not included as an essential health benefit 
     or otherwise covered as a benefit by a health plan. Nothing 
     in subparagraph (B) shall prohibit any type of medical 
     provider from accepting an out-of-pocket payment from an 
     individual enrolled in a community health insurance option 
     for a service otherwise not included as an essential health 
     benefit.
       (F) Protecting access to end of life care.--A community 
     health insurance option offered under this section shall be 
     prohibited from limiting access to end of life care.
       (4) Cost sharing.--A community health insurance option 
     shall offer coverage at each of the levels of coverage 
     described in section 1302(d).
       (5) Premiums.--
       (A) Premiums sufficient to cover costs.--The Secretary 
     shall establish geographically adjusted premium rates in an 
     amount sufficient to cover expected costs (including claims 
     and administrative costs) using methods in general use by 
     qualified health plans.
       (B) Applicable rules.--The provisions of title XXVII of the 
     Public Health Service Act relating to premiums shall apply to 
     community health insurance options under this section, 
     including modified community rating provisions under section 
     2701 of such Act.
       (C) Collection of data.--The Secretary shall collect data 
     as necessary to set premium rates under subparagraph (A).
       (D) National pooling.--Notwithstanding any other provision 
     of law, the Secretary may treat all enrollees in community 
     health insurance options as members of a single pool.
       (E) Contingency margin.--In establishing premium rates 
     under subparagraph (A), the Secretary shall include an 
     appropriate amount for a contingency margin.
       (6) Reimbursement rates.--
       (A) Negotiated rates.--The Secretary shall negotiate rates 
     for the reimbursement of health care providers for benefits 
     covered under a community health insurance option.
       (B) Limitation.--The rates described in subparagraph (A) 
     shall not be higher, in aggregate, than the average 
     reimbursement rates paid by health insurance issuers offering 
     qualified health plans through the Exchange.
       (C) Innovation.--Subject to the limits contained in 
     subparagraph (A), a State Advisory Council established or 
     designated under subsection (d) may develop or encourage the 
     use of innovative payment policies that promote quality, 
     efficiency and savings to consumers.
       (7) Solvency and consumer protection.--
       (A) Solvency.--The Secretary shall establish a Federal 
     solvency standard to be applied with respect to a community 
     health insurance option. A community health insurance option 
     shall also be subject to the solvency standard of each State 
     in which such community health insurance option is offered.
       (B) Minimum required.--In establishing the standard 
     described under subparagraph (A), the Secretary shall require 
     a reserve fund that shall be equal to at least the dollar 
     value of the incurred but not reported claims of a community 
     health insurance option.
       (C) Consumer protections.--The consumer protection laws of 
     a State shall apply to a community health insurance option.
       (8) Requirements established in partnership with insurance 
     commissioners.--
       (A) In general.--The Secretary, in collaboration with the 
     National Association of Insurance Commissioners (in this 
     paragraph referred to as the ``NAIC''), may promulgate 
     regulations to establish additional requirements for a 
     community health insurance option.
       (B) Applicability.--Any requirement promulgated under 
     subparagraph (A) shall be applicable to such option beginning 
     90 days after the date on which the regulation involved 
     becomes final.
       (c) Start-up Fund.--
       (1) Establishment of fund.--
       (A) In general.--There is established in the Treasury of 
     the United States a trust fund to be known as the ``Health 
     Benefit Plan Start-Up Fund'' (referred to in this section as 
     the ``Start-Up Fund''), that shall consist of such amounts as 
     may be appropriated or credited to the Start-Up Fund as 
     provided for in this subsection to provide loans for the 
     initial operations of a community health insurance option. 
     Such amounts shall remain available until expended.
       (B) Funding.--There is hereby appropriated to the Start-Up 
     Fund, out of any moneys in the Treasury not otherwise 
     appropriated an amount requested by the Secretary of Health 
     and Human Services as necessary to--
       (i) pay the start-up costs associated with the initial 
     operations of a community health insurance option; and
       (ii) pay the costs of making payments on claims submitted 
     during the period that is not more than 90 days from the date 
     on which such option is offered.
       (2) Use of start-up fund.--The Secretary shall use amounts 
     contained in the Start-Up Fund to make payments (subject to 
     the repayment requirements in paragraph (4)) for the purposes 
     described in paragraph (1)(B).
       (3) Pass through of rebates.--The Secretary may establish 
     procedures for reducing the amount of payments to a 
     contracting administrator to take into account any rebates or 
     price concessions.
       (4) Repayment.--
       (A) In general.--A community health insurance option shall 
     be required to repay the Secretary of the Treasury (on such 
     terms as the Secretary may require) for any payments made 
     under paragraph (1)(B) by the date that is not later than 9 
     years after the date on which the payment is made. The 
     Secretary may require the payment of interest with respect to 
     such repayments at rates that do not exceed the market 
     interest rate (as determined by the Secretary).
       (B) Sanctions in case of for-profit conversion.--In any 
     case in which the Secretary enters into a contract with a 
     qualified entity for the offering of a community health 
     insurance option and such entity is determined to be a for-
     profit entity by the Secretary, such entity shall be--
       (i) immediately liable to the Secretary for any payments 
     received by such entity from the Start-Up Fund; and
       (ii) permanently ineligible to offer a qualified health 
     plan.
       (d) State Advisory Council.--
       (1) Establishment.--A State (other than a State that elects 
     to opt out as provided for in subsection (a)(3)) shall 
     establish or designate a public or non-profit private entity 
     to serve as the State Advisory Council to provide 
     recommendations to the Secretary on the operations and 
     policies of a community health insurance option in the State. 
     Such Council shall provide recommendations on at least the 
     following:
       (A) policies and procedures to integrate quality 
     improvement and cost containment mechanisms into the health 
     care delivery system;
       (B) mechanisms to facilitate public awareness of the 
     availability of a community health insurance option; and
       (C) alternative payment structures under a community health 
     insurance option for health care providers that encourage 
     quality improvement and cost control.
       (2) Members.--The members of the State Advisory Council 
     shall be representatives of the public and shall include 
     health care consumers and providers.
       (3) Applicability of recommendations.--The Secretary may 
     apply the recommendations of a State Advisory Council to a 
     community health insurance option in that State, in any other 
     State, or in all States.
       (e) Authority To Contract; Terms of Contract.--
       (1) Authority.--
       (A) In general.--The Secretary may enter into a contract or 
     contracts with one or more qualified entities for the purpose 
     of performing administrative functions (including functions 
     described in subsection (a)(4) of section 1874A of the Social 
     Security Act) with respect to a community health insurance 
     option in the same manner as the Secretary may enter into 
     contracts under subsection (a)(1) of such section. The 
     Secretary shall have the same authority with respect to a 
     community health insurance option under this section as the 
     Secretary has under subsections (a)(1) and (b) of section 
     1874A of the Social Security Act with respect to title XVIII 
     of such Act.
       (B) Requirements apply.--If the Secretary enters into a 
     contract with a qualified entity to offer a community health 
     insurance option, under such contract such entity--
       (i) shall meet the criteria established under paragraph 
     (2); and
       (ii) shall receive an administrative fee under paragraph 
     (7).
       (C) Limitation.--Contracts under this subsection shall not 
     involve the transfer of insurance risk to the contracting 
     administrator.
       (D) Reference.--An entity with which the Secretary has 
     entered into a contract under this paragraph shall be 
     referred to as a ``contracting administrator''.
       (2) Qualified entity.--To be qualified to be selected by 
     the Secretary to offer a community health insurance option, 
     an entity shall--
       (A) meet the criteria established under section 1874A(a)(2) 
     of the Social Security Act;
       (B) be a nonprofit entity for purposes of offering such 
     option;
       (C) meet the solvency standards applicable under subsection 
     (b)(7);
       (D) be eligible to offer health insurance or health 
     benefits coverage;
       (E) meet quality standards specified by the Secretary;
       (F) have in place effective procedures to control fraud, 
     abuse, and waste; and
       (G) meet such other requirements as the Secretary may 
     impose.

     Procedures described under subparagraph (F) shall include the 
     implementation of procedures to use beneficiary identifiers 
     to identify individuals entitled to benefits so that such an 
     individual's social security account number is not used, and 
     shall also include procedures for the use of technology 
     (including front-end, prepayment intelligent data-matching 
     technology similar to that used by hedge funds, investment 
     funds, and banks) to provide real-time data analysis of 
     claims for payment under this title to identify and 
     investigate unusual billing or order practices under this 
     title that could indicate fraud or abuse.
       (3) Term.--A contract provided for under paragraph (1) 
     shall be for a term of at least 5 years but not more than 10 
     years, as determined by the Secretary. At the end of each 
     such term, the Secretary shall conduct a competitive bidding 
     process for the purposes of renewing existing contracts or 
     selecting new qualified entities with which to enter into 
     contracts under such paragraph.
       (4) Limitation.--A contract may not be renewed under this 
     subsection unless the Secretary determines that the 
     contracting administrator has met performance requirements 
     established by the Secretary in the areas described in 
     paragraph (7)(B).
       (5) Audits.--The Inspector General shall conduct periodic 
     audits with respect to contracting

[[Page 4225]]

     administrators under this subsection to ensure that the 
     administrator involved is in compliance with this section.
       (6) Revocation.--A contract awarded under this subsection 
     shall be revoked by the Secretary, upon the recommendation of 
     the Inspector General, only after notice to the contracting 
     administrator involved and an opportunity for a hearing. The 
     Secretary may revoke such contract if the Secretary 
     determines that such administrator has engaged in fraud, 
     deception, waste, abuse of power, negligence, mismanagement 
     of taxpayer dollars, or gross mismanagement. An entity that 
     has had a contract revoked under this paragraph shall not be 
     qualified to enter into a subsequent contract under this 
     subsection.
       (7) Fee for administration.--
       (A) In general.--The Secretary shall pay the contracting 
     administrator a fee for the management, administration, and 
     delivery of the benefits under this section.
       (B) Requirement for high quality administration.--The 
     Secretary may increase the fee described in subparagraph (A) 
     by not more than 10 percent, or reduce the fee described in 
     subparagraph (A) by not more than 50 percent, based on the 
     extent to which the contracting administrator, in the 
     determination of the Secretary, meets performance 
     requirements established by the Secretary, in at least the 
     following areas:
       (i) Maintaining low premium costs and low cost sharing 
     requirements, provided that such requirements are consistent 
     with section 1302.
       (ii) Reducing administrative costs and promoting 
     administrative simplification for beneficiaries.
       (iii) Promoting high quality clinical care.
       (iv) Providing high quality customer service to 
     beneficiaries.
       (C) Non-renewal.--The Secretary may not renew a contract to 
     offer a community health insurance option under this section 
     with any contracting entity that has been assessed more than 
     one reduction under subparagraph (B) during the contract 
     period.
       (8) Limitation.--Notwithstanding the terms of a contract 
     under this subsection, the Secretary shall negotiate the 
     reimbursement rates for purposes of subsection (b)(6).
       (f) Report by HHS and Insolvency Warnings.--
       (1) In general.--On an annual basis, the Secretary shall 
     conduct a study on the solvency of a community health 
     insurance option and submit to Congress a report describing 
     the results of such study.
       (2) Result.--If, in any year, the result of the study under 
     paragraph (1) is that a community health insurance option is 
     insolvent, such result shall be treated as a community health 
     insurance option solvency warning.
       (3) Submission of plan and procedure.--
       (A) In general.--If there is a community health insurance 
     option solvency warning under paragraph (2) made in a year, 
     the President shall submit to Congress, within the 15-day 
     period beginning on the date of the budget submission to 
     Congress under section 1105(a) of title 31, United States 
     Code, for the succeeding year, proposed legislation to 
     respond to such warning.
       (B) Procedure.--In the case of a legislative proposal 
     submitted by the President pursuant to subparagraph (A), such 
     proposal shall be considered by Congress using the same 
     procedures described under sections 803 and 804 of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 that shall be used for a medicare funding 
     warning.
       (g) Marketing Parity.--In a facility controlled by the 
     Federal Government, or by a State, where marketing or 
     promotional materials related to a community health insurance 
     option are made available to the public, making available 
     marketing or promotional materials relating to private health 
     insurance plans shall not be prohibited. Such materials 
     include informational pamphlets, guidebooks, enrollment 
     forms, or other materials determined reasonable for display.
       (h) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     SEC. 1324. LEVEL PLAYING FIELD.

       (a) In General.--Notwithstanding any other provision of 
     law, any health insurance coverage offered by a private 
     health insurance issuer shall not be subject to any Federal 
     or State law described in subsection (b) if a qualified 
     health plan offered under the Consumer Operated and Oriented 
     Plan program under section 1322, a community health insurance 
     option under section 1323, or a nationwide qualified health 
     plan under section 1333(b), is not subject to such law.
       (b) Laws Described.--The Federal and State laws described 
     in this subsection are those Federal and State laws relating 
     to--
       (1) guaranteed renewal;
       (2) rating;
       (3) preexisting conditions;
       (4) non-discrimination;
       (5) quality improvement and reporting;
       (6) fraud and abuse;
       (7) solvency and financial requirements;
       (8) market conduct;
       (9) prompt payment;
       (10) appeals and grievances;
       (11) privacy and confidentiality;
       (12) licensure; and
       (13) benefit plan material or information.

      PART IV--STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS

     SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH 
                   PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT 
                   ELIGIBLE FOR MEDICAID.

       (a) Establishment of Program.--
       (1) In general.--The Secretary shall establish a basic 
     health program meeting the requirements of this section under 
     which a State may enter into contracts to offer 1 or more 
     standard health plans providing at least the essential health 
     benefits described in section 1302(b) to eligible individuals 
     in lieu of offering such individuals coverage through an 
     Exchange.
       (2) Certifications as to benefit coverage and costs.--Such 
     program shall provide that a State may not establish a basic 
     health program under this section unless the State 
     establishes to the satisfaction of the Secretary, and the 
     Secretary certifies, that--
       (A) in the case of an eligible individual enrolled in a 
     standard health plan offered through the program, the State 
     provides--
       (i) that the amount of the monthly premium an eligible 
     individual is required to pay for coverage under the standard 
     health plan for the individual and the individual's 
     dependents does not exceed the amount of the monthly premium 
     that the eligible individual would have been required to pay 
     (in the rating area in which the individual resides) if the 
     individual had enrolled in the applicable second lowest cost 
     silver plan (as defined in section 36B(b)(3)(B) of the 
     Internal Revenue Code of 1986) offered to the individual 
     through an Exchange; and
       (ii) that the cost-sharing an eligible individual is 
     required to pay under the standard health plan does not 
     exceed--

       (I) the cost-sharing required under a platinum plan in the 
     case of an eligible individual with household income not in 
     excess of 150 percent of the poverty line for the size of the 
     family involved; and
       (II) the cost-sharing required under a gold plan in the 
     case of an eligible individual not described in subclause 
     (I); and

       (B) the benefits provided under the standard health plans 
     offered through the program cover at least the essential 
     health benefits described in section 1302(b).

     For purposes of subparagraph (A)(i), the amount of the 
     monthly premium an individual is required to pay under either 
     the standard health plan or the applicable second lowest cost 
     silver plan shall be determined after reduction for any 
     premium tax credits and cost-sharing reductions allowable 
     with respect to either plan.
       (b) Standard Health Plan.--In this section, the term 
     ``standard heath plan'' means a health benefits plan that the 
     State contracts with under this section--
       (1) under which the only individuals eligible to enroll are 
     eligible individuals;
       (2) that provides at least the essential health benefits 
     described in section 1302(b); and
       (3) in the case of a plan that provides health insurance 
     coverage offered by a health insurance issuer, that has a 
     medical loss ratio of at least 85 percent.
       (c) Contracting Process.--
       (1) In general.--A State basic health program shall 
     establish a competitive process for entering into contracts 
     with standard health plans under subsection (a), including 
     negotiation of premiums and cost-sharing and negotiation of 
     benefits in addition to the essential health benefits 
     described in section 1302(b).
       (2) Specific items to be considered.--A State shall, as 
     part of its competitive process under paragraph (1), include 
     at least the following:
       (A) Innovation.--Negotiation with offerors of a standard 
     health plan for the inclusion of innovative features in the 
     plan, including--
       (i) care coordination and care management for enrollees, 
     especially for those with chronic health conditions;
       (ii) incentives for use of preventive services; and
       (iii) the establishment of relationships between providers 
     and patients that maximize patient involvement in health care 
     decision-making, including providing incentives for 
     appropriate utilization under the plan.
       (B) Health and resource differences.--Consideration of, and 
     the making of suitable allowances for, differences in health 
     care needs of enrollees and differences in local availability 
     of, and access to, health care providers. Nothing in this 
     subparagraph shall be construed as allowing discrimination on 
     the basis of pre-existing conditions or other health status-
     related factors.
       (C) Managed care.--Contracting with managed care systems, 
     or with systems that offer as many of the attributes of 
     managed care as are feasible in the local health care market.
       (D) Performance measures.--Establishing specific 
     performance measures and standards for issuers of standard 
     health plans that focus on quality of care and improved 
     health outcomes, requiring such plans to report to the State 
     with respect to the measures and standards, and making the 
     performance and quality information available to enrollees in 
     a useful form.
       (3) Enhanced availability.--
       (A) Multiple plans.--A State shall, to the maximum extent 
     feasible, seek to make multiple standard health plans 
     available to eligible individuals within a State to ensure 
     individuals have a choice of such plans.
       (B) Regional compacts.--A State may negotiate a regional 
     compact with other States to include coverage of eligible 
     individuals in all such States in agreements with issuers of 
     standard health plans.
       (4) Coordination with other state programs.--A State shall 
     seek to coordinate the administration of, and provision of 
     benefits under, its program under this section with the State 
     medicaid program under title XIX of the Social

[[Page 4226]]

     Security Act, the State child health plan under title XXI of 
     such Act, and other State-administered health programs to 
     maximize the efficiency of such programs and to improve the 
     continuity of care.
       (d) Transfer of Funds to States.--
       (1) In general.--If the Secretary determines that a State 
     electing the application of this section meets the 
     requirements of the program established under subsection (a), 
     the Secretary shall transfer to the State for each fiscal 
     year for which 1 or more standard health plans are operating 
     within the State the amount determined under paragraph (3).
       (2) Use of funds.--A State shall establish a trust for the 
     deposit of the amounts received under paragraph (1) and 
     amounts in the trust fund shall only be used to reduce the 
     premiums and cost-sharing of, or to provide additional 
     benefits for, eligible individuals enrolled in standard 
     health plans within the State. Amounts in the trust fund, and 
     expenditures of such amounts, shall not be included in 
     determining the amount of any non-Federal funds for purposes 
     of meeting any matching or expenditure requirement of any 
     federally-funded program.
       (3) Amount of payment.--
       (A) Secretarial determination.--
       (i) In general.--The amount determined under this paragraph 
     for any fiscal year is the amount the Secretary determines is 
     equal to 85 percent of the premium tax credits under section 
     36B of the Internal Revenue Code of 1986, and the cost-
     sharing reductions under section 1402, that would have been 
     provided for the fiscal year to eligible individuals enrolled 
     in standard health plans in the State if such eligible 
     individuals were allowed to enroll in qualified health plans 
     through an Exchange established under this subtitle.
       (ii) Specific requirements.--The Secretary shall make the 
     determination under clause (i) on a per enrollee basis and 
     shall take into account all relevant factors necessary to 
     determine the value of the premium tax credits and cost-
     sharing reductions that would have been provided to eligible 
     individuals described in clause (i), including the age and 
     income of the enrollee, whether the enrollment is for self-
     only or family coverage, geographic differences in average 
     spending for health care across rating areas, the health 
     status of the enrollee for purposes of determining risk 
     adjustment payments and reinsurance payments that would have 
     been made if the enrollee had enrolled in a qualified health 
     plan through an Exchange, and whether any reconciliation of 
     the credit or cost-sharing reductions would have occurred if 
     the enrollee had been so enrolled. This determination shall 
     take into consideration the experience of other States with 
     respect to participation in an Exchange and such credits and 
     reductions provided to residents of the other States, with a 
     special focus on enrollees with income below 200 percent of 
     poverty.
       (iii) Certification.--The Chief Actuary of the Centers for 
     Medicare & Medicaid Services, in consultation with the Office 
     of Tax Analysis of the Department of the Treasury, shall 
     certify whether the methodology used to make determinations 
     under this subparagraph, and such determinations, meet the 
     requirements of clause (ii). Such certifications shall be 
     based on sufficient data from the State and from comparable 
     States about their experience with programs created by this 
     Act.
       (B) Corrections.--The Secretary shall adjust the payment 
     for any fiscal year to reflect any error in the 
     determinations under subparagraph (A) for any preceding 
     fiscal year.
       (4) Application of special rules.--The provisions of 
     section 1303 shall apply to a State basic health program, and 
     to standard health plans offered through such program, in the 
     same manner as such rules apply to qualified health plans.
       (e) Eligible Individual.--
       (1) In general.--In this section, the term ``eligible 
     individual'' means, with respect to any State, an 
     individual--
       (A) who a resident of the State who is not eligible to 
     enroll in the State's medicaid program under title XIX of the 
     Social Security Act for benefits that at a minimum consist of 
     the essential health benefits described in section 1302(b);
       (B) whose household income exceeds 133 percent but does not 
     exceed 200 percent of the poverty line for the size of the 
     family involved;
       (C) who is not eligible for minimum essential coverage (as 
     defined in section 5000A(f) of the Internal Revenue Code of 
     1986) or is eligible for an employer-sponsored plan that is 
     not affordable coverage (as determined under section 
     5000A(e)(2) of such Code); and
       (D) who has not attained age 65 as of the beginning of the 
     plan year.

     Such term shall not include any individual who is not a 
     qualified individual under section 1312 who is eligible to be 
     covered by a qualified health plan offered through an 
     Exchange.
       (2) Eligible individuals may not use exchange.--An eligible 
     individual shall not be treated as a qualified individual 
     under section 1312 eligible for enrollment in a qualified 
     health plan offered through an Exchange established under 
     section 1311.
       (f) Secretarial Oversight.--The Secretary shall each year 
     conduct a review of each State program to ensure compliance 
     with the requirements of this section, including ensuring 
     that the State program meets--
       (1) eligibility verification requirements for participation 
     in the program;
       (2) the requirements for use of Federal funds received by 
     the program; and
       (3) the quality and performance standards under this 
     section.
       (g) Standard Health Plan Offerors.--A State may provide 
     that persons eligible to offer standard health plans under a 
     basic health program established under this section may 
     include a licensed health maintenance organization, a 
     licensed health insurance insurer, or a network of health 
     care providers established to offer services under the 
     program.
       (h) Definitions.--Any term used in this section which is 
     also used in section 36B of the Internal Revenue Code of 1986 
     shall have the meaning given such term by such section.

     SEC. 1332. WAIVER FOR STATE INNOVATION.

       (a) Application.--
       (1) In general.--A State may apply to the Secretary for the 
     waiver of all or any requirements described in paragraph (2) 
     with respect to health insurance coverage within that State 
     for plan years beginning on or after January 1, 2017. Such 
     application shall--
       (A) be filed at such time and in such manner as the 
     Secretary may require;
       (B) contain such information as the Secretary may require, 
     including--
       (i) a comprehensive description of the State legislation 
     and program to implement a plan meeting the requirements for 
     a waiver under this section; and
       (ii) a 10-year budget plan for such plan that is budget 
     neutral for the Federal Government; and
       (C) provide an assurance that the State has enacted the law 
     described in subsection (b)(2).
       (2) Requirements.--The requirements described in this 
     paragraph with respect to health insurance coverage within 
     the State for plan years beginning on or after January 1, 
     2014, are as follows:
       (A) Part I of subtitle D.
       (B) Part II of subtitle D.
       (C) Section 1402.
       (D) Sections 36B, 4980H, and 5000A of the Internal Revenue 
     Code of 1986.
       (3) Pass through of funding.--With respect to a State 
     waiver under paragraph (1), under which, due to the structure 
     of the State plan, individuals and small employers in the 
     State would not qualify for the premium tax credits, cost-
     sharing reductions, or small business credits under sections 
     36B of the Internal Revenue Code of 1986 or under part I of 
     subtitle E for which they would otherwise be eligible, the 
     Secretary shall provide for an alternative means by which the 
     aggregate amount of such credits or reductions that would 
     have been paid on behalf of participants in the Exchanges 
     established under this title had the State not received such 
     waiver, shall be paid to the State for purposes of 
     implementing the State plan under the waiver. Such amount 
     shall be determined annually by the Secretary, taking into 
     consideration the experience of other States with respect to 
     participation in an Exchange and credits and reductions 
     provided under such provisions to residents of the other 
     States.
       (4) Waiver consideration and transparency.--
       (A) In general.--An application for a waiver under this 
     section shall be considered by the Secretary in accordance 
     with the regulations described in subparagraph (B).
       (B) Regulations.--Not later than 180 days after the date of 
     enactment of this Act, the Secretary shall promulgate 
     regulations relating to waivers under this section that 
     provide--
       (i) a process for public notice and comment at the State 
     level, including public hearings, sufficient to ensure a 
     meaningful level of public input;
       (ii) a process for the submission of an application that 
     ensures the disclosure of--

       (I) the provisions of law that the State involved seeks to 
     waive; and
       (II) the specific plans of the State to ensure that the 
     waiver will be in compliance with subsection (b);

       (iii) a process for providing public notice and comment 
     after the application is received by the Secretary, that is 
     sufficient to ensure a meaningful level of public input and 
     that does not impose requirements that are in addition to, or 
     duplicative of, requirements imposed under the Administrative 
     Procedures Act, or requirements that are unreasonable or 
     unnecessarily burdensome with respect to State compliance;
       (iv) a process for the submission to the Secretary of 
     periodic reports by the State concerning the implementation 
     of the program under the waiver; and
       (v) a process for the periodic evaluation by the Secretary 
     of the program under the waiver.
       (C) Report.--The Secretary shall annually report to 
     Congress concerning actions taken by the Secretary with 
     respect to applications for waivers under this section.
       (5) Coordinated waiver process.--The Secretary shall 
     develop a process for coordinating and consolidating the 
     State waiver processes applicable under the provisions of 
     this section, and the existing waiver processes applicable 
     under titles XVIII, XIX, and XXI of the Social Security Act, 
     and any other Federal law relating to the provision of health 
     care items or services. Such process shall permit a State to 
     submit a single application for a waiver under any or all of 
     such provisions.
       (6) Definition.--In this section, the term ``Secretary'' 
     means--
       (A) the Secretary of Health and Human Services with respect 
     to waivers relating to the provisions described in 
     subparagraph (A) through (C) of paragraph (2); and
       (B) the Secretary of the Treasury with respect to waivers 
     relating to the provisions described in paragraph (2)(D).

[[Page 4227]]

       (b) Granting of Waivers.--
       (1) In general.--The Secretary may grant a request for a 
     waiver under subsection (a)(1) only if the Secretary 
     determines that the State plan--
       (A) will provide coverage that is at least as comprehensive 
     as the coverage defined in section 1302(b) and offered 
     through Exchanges established under this title as certified 
     by Office of the Actuary of the Centers for Medicare & 
     Medicaid Services based on sufficient data from the State and 
     from comparable States about their experience with programs 
     created by this Act and the provisions of this Act that would 
     be waived;
       (B) will provide coverage and cost sharing protections 
     against excessive out-of-pocket spending that are at least as 
     affordable as the provisions of this title would provide;
       (C) will provide coverage to at least a comparable number 
     of its residents as the provisions of this title would 
     provide; and
       (D) will not increase the Federal deficit.
       (2) Requirement to enact a law.--
       (A) In general.--A law described in this paragraph is a 
     State law that provides for State actions under a waiver 
     under this section, including the implementation of the State 
     plan under subsection (a)(1)(B).
       (B) Termination of opt out.--A State may repeal a law 
     described in subparagraph (A) and terminate the authority 
     provided under the waiver with respect to the State.
       (c) Scope of Waiver.--
       (1) In general.--The Secretary shall determine the scope of 
     a waiver of a requirement described in subsection (a)(2) 
     granted to a State under subsection (a)(1).
       (2) Limitation.--The Secretary may not waive under this 
     section any Federal law or requirement that is not within the 
     authority of the Secretary.
       (d) Determinations by Secretary.--
       (1) Time for determination.--The Secretary shall make a 
     determination under subsection (a)(1) not later than 180 days 
     after the receipt of an application from a State under such 
     subsection.
       (2) Effect of determination.--
       (A) Granting of waivers.--If the Secretary determines to 
     grant a waiver under subsection (a)(1), the Secretary shall 
     notify the State involved of such determination and the terms 
     and effectiveness of such waiver.
       (B) Denial of waiver.--If the Secretary determines a waiver 
     should not be granted under subsection (a)(1), the Secretary 
     shall notify the State involved, and the appropriate 
     committees of Congress of such determination and the reasons 
     therefore.
       (e) Term of Waiver.--No waiver under this section may 
     extend over a period of longer than 5 years unless the State 
     requests continuation of such waiver, and such request shall 
     be deemed granted unless the Secretary, within 90 days after 
     the date of its submission to the Secretary, either denies 
     such request in writing or informs the State in writing with 
     respect to any additional information which is needed in 
     order to make a final determination with respect to the 
     request.

     SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE 
                   THAN ONE STATE.

       (a) Health Care Choice Compacts.--
       (1) In general.--Not later than July 1, 2013, the Secretary 
     shall, in consultation with the National Association of 
     Insurance Commissioners, issue regulations for the creation 
     of health care choice compacts under which 2 or more States 
     may enter into an agreement under which--
       (A) 1 or more qualified health plans could be offered in 
     the individual markets in all such States but, except as 
     provided in subparagraph (B), only be subject to the laws and 
     regulations of the State in which the plan was written or 
     issued;
       (B) the issuer of any qualified health plan to which the 
     compact applies--
       (i) would continue to be subject to market conduct, unfair 
     trade practices, network adequacy, and consumer protection 
     standards (including standards relating to rating), including 
     addressing disputes as to the performance of the contract, of 
     the State in which the purchaser resides;
       (ii) would be required to be licensed in each State in 
     which it offers the plan under the compact or to submit to 
     the jurisdiction of each such State with regard to the 
     standards described in clause (i) (including allowing access 
     to records as if the insurer were licensed in the State); and
       (iii) must clearly notify consumers that the policy may not 
     be subject to all the laws and regulations of the State in 
     which the purchaser resides.
       (2) State authority.--A State may not enter into an 
     agreement under this subsection unless the State enacts a law 
     after the date of the enactment of this title that 
     specifically authorizes the State to enter into such 
     agreements.
       (3) Approval of compacts.--The Secretary may approve 
     interstate health care choice compacts under paragraph (1) 
     only if the Secretary determines that such health care choice 
     compact--
       (A) will provide coverage that is at least as comprehensive 
     as the coverage defined in section 1302(b) and offered 
     through Exchanges established under this title;
       (B) will provide coverage and cost sharing protections 
     against excessive out-of-pocket spending that are at least as 
     affordable as the provisions of this title would provide;
       (C) will provide coverage to at least a comparable number 
     of its residents as the provisions of this title would 
     provide;
       (D) will not increase the Federal deficit; and
       (E) will not weaken enforcement of laws and regulations 
     described in paragraph (1)(B)(i) in any State that is 
     included in such compact.
       (4) Effective date.--A health care choice compact described 
     in paragraph (1) shall not take effect before January 1, 
     2016.
       (b) Authority for Nationwide Plans.--
       (1) In general.--Except as provided in paragraph (2), if an 
     issuer (including a group of health insurance issuers 
     affiliated either by common ownership and control or by the 
     common use of a nationally licensed service mark) of a 
     qualified health plan in the individual or small group market 
     meets the requirements of this subsection (in this subsection 
     a ``nationwide qualified health plan'')--
       (A) the issuer of the plan may offer the nationwide 
     qualified health plan in the individual or small group market 
     in more than 1 State; and
       (B) with respect to State laws mandating benefit coverage 
     by a health plan, only the State laws of the State in which 
     such plan is written or issued shall apply to the nationwide 
     qualified health plan.
       (2) State opt-out.--A State may, by specific reference in a 
     law enacted after the date of enactment of this title, 
     provide that this subsection shall not apply to that State. 
     Such opt-out shall be effective until such time as the State 
     by law revokes it.
       (3) Plan requirements.--An issuer meets the requirements of 
     this subsection with respect to a nationwide qualified health 
     plan if, in the determination of the Secretary--
       (A) the plan offers a benefits package that is uniform in 
     each State in which the plan is offered and meets the 
     requirements set forth in paragraphs (4) through (6);
       (B) the issuer is licensed in each State in which it offers 
     the plan and is subject to all requirements of State law not 
     inconsistent with this section, including but not limited to, 
     the standards and requirements that a State imposes that do 
     not prevent the application of a requirement of part A of 
     title XXVII of the Public Health Service Act or a requirement 
     of this title;
       (C) the issuer meets all requirements of this title with 
     respect to a qualified health plan, including the requirement 
     to offer the silver and gold levels of the plan in each 
     Exchange in the State for the market in which the plan is 
     offered;
       (D) the issuer determines the premiums for the plan in any 
     State on the basis of the rating rules in effect in that 
     State for the rating areas in which it is offered;
       (E) the issuer offers the nationwide qualified health plan 
     in at least 60 percent of the participating States in the 
     first year in which the plan is offered, 65 percent of such 
     States in the second year, 70 percent of such States in the 
     third year, 75 percent of such States in the fourth year, and 
     80 percent of such States in the fifth and subsequent years;
       (F) the issuer shall offer the plan in participating States 
     across the country, in all geographic regions, and in all 
     States that have adopted adjusted community rating before the 
     date of enactment of this Act; and
       (G) the issuer clearly notifies consumers that the policy 
     may not contain some benefits otherwise mandated for plans in 
     the State in which the purchaser resides and provides a 
     detailed statement of the benefits offered and the benefit 
     differences in that State, in accordance with rules 
     promulgated by the Secretary.
       (4) Form review for nationwide plans.--Notwithstanding any 
     contrary provision of State law, at least 3 months before any 
     nationwide qualified health plan is offered, the issuer shall 
     file all nationwide qualified health plan forms with the 
     regulator in each participating State in which the plan will 
     be offered. An issuer may appeal the disapproval of a 
     nationwide qualified health plan form to the Secretary.
       (5) Applicable rules.--The Secretary shall, in consultation 
     with the National Association of Insurance Commissioners, 
     issue rules for the offering of nationwide qualified health 
     plans under this subsection. Nationwide qualified health 
     plans may be offered only after such rules have taken effect.
       (6) Coverage.--The Secretary shall provide that the health 
     benefits coverage provided to an individual through a 
     nationwide qualified health plan under this subsection shall 
     include at least the essential benefits package described in 
     section 1302.
       (7) State law mandating benefit coverage by a health 
     benefits plan.--For the purposes of this subsection, a State 
     law mandating benefit coverage by a health plan is a law that 
     mandates health insurance coverage or the offer of health 
     insurance coverage for specific health services or specific 
     diseases. A law that mandates health insurance coverage or 
     reimbursement for services provided by certain classes of 
     providers of health care services, or a law that mandates 
     that certain classes of individuals must be covered as a 
     group or as dependents, is not a State law mandating benefit 
     coverage by a health benefits plan.

                PART V--REINSURANCE AND RISK ADJUSTMENT

     SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL 
                   AND SMALL GROUP MARKETS IN EACH STATE.

       (a) In General.--Each State shall, not later than January 
     1, 2014--
       (1) include in the Federal standards or State law or 
     regulation the State adopts and has in effect under section 
     1321(b) the provisions described in subsection (b); and

[[Page 4228]]

       (2) establish (or enter into a contract with) 1 or more 
     applicable reinsurance entities to carry out the reinsurance 
     program under this section.
       (b) Model Regulation.--
       (1) In general.--In establishing the Federal standards 
     under section 1321(a), the Secretary, in consultation with 
     the National Association of Insurance Commissioners (the 
     ``NAIC''), shall include provisions that enable States to 
     establish and maintain a program under which--
       (A) health insurance issuers, and third party 
     administrators on behalf of group health plans, are required 
     to make payments to an applicable reinsurance entity for any 
     plan year beginning in the 3-year period beginning January 1, 
     2014 (as specified in paragraph (3); and
       (B) the applicable reinsurance entity collects payments 
     under subparagraph (A) and uses amounts so collected to make 
     reinsurance payments to health insurance issuers described in 
     subparagraph (A) that cover high risk individuals in the 
     individual market (excluding grandfathered health plans) for 
     any plan year beginning in such 3-year period.
       (2) High-risk individual; payment amounts.--The Secretary 
     shall include the following in the provisions under paragraph 
     (1):
       (A) Determination of high-risk individuals.--The method by 
     which individuals will be identified as high risk individuals 
     for purposes of the reinsurance program established under 
     this section. Such method shall provide for identification of 
     individuals as high-risk individuals on the basis of--
       (i) a list of at least 50 but not more than 100 medical 
     conditions that are identified as high-risk conditions and 
     that may be based on the identification of diagnostic and 
     procedure codes that are indicative of individuals with pre-
     existing, high-risk conditions; or
       (ii) any other comparable objective method of 
     identification recommended by the American Academy of 
     Actuaries.
       (B) Payment amount.--The formula for determining the amount 
     of payments that will be paid to health insurance issuers 
     described in paragraph (1)(A) that insure high-risk 
     individuals. Such formula shall provide for the equitable 
     allocation of available funds through reconciliation and may 
     be designed--
       (i) to provide a schedule of payments that specifies the 
     amount that will be paid for each of the conditions 
     identified under subparagraph (A); or
       (ii) to use any other comparable method for determining 
     payment amounts that is recommended by the American Academy 
     of Actuaries and that encourages the use of care coordination 
     and care management programs for high risk conditions.
       (3) Determination of required contributions.--
       (A) In general.--The Secretary shall include in the 
     provisions under paragraph (1) the method for determining the 
     amount each health insurance issuer and group health plan 
     described in paragraph (1)(A) contributing to the reinsurance 
     program under this section is required to contribute under 
     such paragraph for each plan year beginning in the 36-month 
     period beginning January 1, 2014. The contribution amount for 
     any plan year may be based on the percentage of revenue of 
     each issuer and the total costs of providing benefits to 
     enrollees in self-insured plans or on a specified amount per 
     enrollee and may be required to be paid in advance or 
     periodically throughout the plan year.
       (B) Specific requirements.--The method under this paragraph 
     shall be designed so that--
       (i) the contribution amount for each issuer proportionally 
     reflects each issuer's fully insured commercial book of 
     business for all major medical products and the total value 
     of all fees charged by the issuer and the costs of coverage 
     administered by the issuer as a third party administrator;
       (ii) the contribution amount can include an additional 
     amount to fund the administrative expenses of the applicable 
     reinsurance entity;
       (iii) the aggregate contribution amounts for all States 
     shall, based on the best estimates of the NAIC and without 
     regard to amounts described in clause (ii), equal 
     $10,000,000,000 for plan years beginning in 2014, 
     $6,000,000,000 for plan years beginning 2015, and 
     $4,000,000,000 for plan years beginning in 2016; and
       (iv) in addition to the aggregate contribution amounts 
     under clause (iii), each issuer's contribution amount for any 
     calendar year under clause (iii) reflects its proportionate 
     share of an additional $2,000,000,000 for 2014, an additional 
     $2,000,000,000 for 2015, and an additional $1,000,000,000 for 
     2016.

     Nothing in this subparagraph shall be construed to preclude a 
     State from collecting additional amounts from issuers on a 
     voluntary basis.
       (4) Expenditure of funds.--The provisions under paragraph 
     (1) shall provide that--
       (A) the contribution amounts collected for any calendar 
     year may be allocated and used in any of the three calendar 
     years for which amounts are collected based on the 
     reinsurance needs of a particular period or to reflect 
     experience in a prior period; and
       (B) amounts remaining unexpended as of December, 2016, may 
     be used to make payments under any reinsurance program of a 
     State in the individual market in effect in the 2-year period 
     beginning on January 1, 2017.

     Notwithstanding the preceding sentence, any contribution 
     amounts described in paragraph (3)(B)(iv) shall be deposited 
     into the general fund of the Treasury of the United States 
     and may not be used for the program established under this 
     section.
       (c) Applicable Reinsurance Entity.--For purposes of this 
     section--
       (1) In general.--The term ``applicable reinsurance entity'' 
     means a not-for-profit organization--
       (A) the purpose of which is to help stabilize premiums for 
     coverage in the individual and small group markets in a State 
     during the first 3 years of operation of an Exchange for such 
     markets within the State when the risk of adverse selection 
     related to new rating rules and market changes is greatest; 
     and
       (B) the duties of which shall be to carry out the 
     reinsurance program under this section by coordinating the 
     funding and operation of the risk-spreading mechanisms 
     designed to implement the reinsurance program.
       (2) State discretion.--A State may have more than 1 
     applicable reinsurance entity to carry out the reinsurance 
     program under this section within the State and 2 or more 
     States may enter into agreements to provide for an applicable 
     reinsurance entity to carry out such program in all such 
     States.
       (3) Entities are tax-exempt.--An applicable reinsurance 
     entity established under this section shall be exempt from 
     taxation under chapter 1 of the Internal Revenue Code of 
     1986. The preceding sentence shall not apply to the tax 
     imposed by section 511 such Code (relating to tax on 
     unrelated business taxable income of an exempt organization).
       (d) Coordination With State High-risk Pools.--The State 
     shall eliminate or modify any State high-risk pool to the 
     extent necessary to carry out the reinsurance program 
     established under this section. The State may coordinate the 
     State high-risk pool with such program to the extent not 
     inconsistent with the provisions of this section.

     SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN 
                   INDIVIDUAL AND SMALL GROUP MARKETS.

       (a) In General.--The Secretary shall establish and 
     administer a program of risk corridors for calendar years 
     2014, 2015, and 2016 under which a qualified health plan 
     offered in the individual or small group market shall 
     participate in a payment adjustment system based on the ratio 
     of the allowable costs of the plan to the plan's aggregate 
     premiums. Such program shall be based on the program for 
     regional participating provider organizations under part D of 
     title XVIII of the Social Security Act.
       (b) Payment Methodology.--
       (1) Payments out.--The Secretary shall provide under the 
     program established under subsection (a) that if--
       (A) a participating plan's allowable costs for any plan 
     year are more than 103 percent but not more than 108 percent 
     of the target amount, the Secretary shall pay to the plan an 
     amount equal to 50 percent of the target amount in excess of 
     103 percent of the target amount; and
       (B) a participating plan's allowable costs for any plan 
     year are more than 108 percent of the target amount, the 
     Secretary shall pay to the plan an amount equal to the sum of 
     2.5 percent of the target amount plus 80 percent of allowable 
     costs in excess of 108 percent of the target amount.
       (2) Payments in.--The Secretary shall provide under the 
     program established under subsection (a) that if--
       (A) a participating plan's allowable costs for any plan 
     year are less than 97 percent but not less than 92 percent of 
     the target amount, the plan shall pay to the Secretary an 
     amount equal to 50 percent of the excess of 97 percent of the 
     target amount over the allowable costs; and
       (B) a participating plan's allowable costs for any plan 
     year are less than 92 percent of the target amount, the plan 
     shall pay to the Secretary an amount equal to the sum of 2.5 
     percent of the target amount plus 80 percent of the excess of 
     92 percent of the target amount over the allowable costs.
       (c) Definitions.--In this section:
       (1) Allowable costs.--
       (A) In general.--The amount of allowable costs of a plan 
     for any year is an amount equal to the total costs (other 
     than administrative costs) of the plan in providing benefits 
     covered by the plan.
       (B) Reduction for risk adjustment and reinsurance 
     payments.--Allowable costs shall reduced by any risk 
     adjustment and reinsurance payments received under section 
     1341 and 1343.
       (2) Target amount.--The target amount of a plan for any 
     year is an amount equal to the total premiums (including any 
     premium subsidies under any governmental program), reduced by 
     the administrative costs of the plan.

     SEC. 1343. RISK ADJUSTMENT.

       (a) In General.--
       (1) Low actuarial risk plans.--Using the criteria and 
     methods developed under subsection (b), each State shall 
     assess a charge on health plans and health insurance issuers 
     (with respect to health insurance coverage) described in 
     subsection (c) if the actuarial risk of the enrollees of such 
     plans or coverage for a year is less than the average 
     actuarial risk of all enrollees in all plans or coverage in 
     such State for such year that are not self-insured group 
     health plans (which are subject to the provisions of the 
     Employee Retirement Income Security Act of 1974).
       (2) High actuarial risk plans.--Using the criteria and 
     methods developed under subsection (b), each State shall 
     provide a payment to health plans and health insurance 
     issuers (with respect to health insurance coverage) described 
     in subsection (c) if the actuarial risk of the enrollees of 
     such plans or coverage for a year is

[[Page 4229]]

     greater than the average actuarial risk of all enrollees in 
     all plans and coverage in such State for such year that are 
     not self-insured group health plans (which are subject to the 
     provisions of the Employee Retirement Income Security Act of 
     1974).
       (b) Criteria and Methods.--The Secretary, in consultation 
     with States, shall establish criteria and methods to be used 
     in carrying out the risk adjustment activities under this 
     section. The Secretary may utilize criteria and methods 
     similar to the criteria and methods utilized under part C or 
     D of title XVIII of the Social Security Act. Such criteria 
     and methods shall be included in the standards and 
     requirements the Secretary prescribes under section 1321.
       (c) Scope.--A health plan or a health insurance issuer is 
     described in this subsection if such health plan or health 
     insurance issuer provides coverage in the individual or small 
     group market within the State. This subsection shall not 
     apply to a grandfathered health plan or the issuer of a 
     grandfathered health plan with respect to that plan.

       Subtitle E--Affordable Coverage Choices for All Americans

        PART I--PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS

       Subpart A--Premium Tax Credits and Cost-sharing Reductions

     SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE 
                   FOR COVERAGE UNDER A QUALIFIED HEALTH PLAN.

       (a) In General.--Subpart C of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     refundable credits) is amended by inserting after section 36A 
     the following new section:

     ``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED 
                   HEALTH PLAN.

       ``(a) In General.--In the case of an applicable taxpayer, 
     there shall be allowed as a credit against the tax imposed by 
     this subtitle for any taxable year an amount equal to the 
     premium assistance credit amount of the taxpayer for the 
     taxable year.
       ``(b) Premium Assistance Credit Amount.--For purposes of 
     this section--
       ``(1) In general.--The term `premium assistance credit 
     amount' means, with respect to any taxable year, the sum of 
     the premium assistance amounts determined under paragraph (2) 
     with respect to all coverage months of the taxpayer occurring 
     during the taxable year.
       ``(2) Premium assistance amount.--The premium assistance 
     amount determined under this subsection with respect to any 
     coverage month is the amount equal to the lesser of--
       ``(A) the monthly premiums for such month for 1 or more 
     qualified health plans offered in the individual market 
     within a State which cover the taxpayer, the taxpayer's 
     spouse, or any dependent (as defined in section 152) of the 
     taxpayer and which were enrolled in through an Exchange 
     established by the State under 1311 of the Patient Protection 
     and Affordable Care Act, or
       ``(B) the excess (if any) of--
       ``(i) the adjusted monthly premium for such month for the 
     applicable second lowest cost silver plan with respect to the 
     taxpayer, over
       ``(ii) an amount equal to 1/12 of the product of the 
     applicable percentage and the taxpayer's household income for 
     the taxable year.
       ``(3) Other terms and rules relating to premium assistance 
     amounts.--For purposes of paragraph (2)--
       ``(A) Applicable percentage.--
       ``(i) In general.--Except as provided in clause (ii), the 
     applicable percentage with respect to any taxpayer for any 
     taxable year is equal to 2.8 percent, increased by the number 
     of percentage points (not greater than 7) which bears the 
     same ratio to 7 percentage points as--

       ``(I) the taxpayer's household income for the taxable year 
     in excess of 100 percent of the poverty line for a family of 
     the size involved, bears to
       ``(II) an amount equal to 200 percent of the poverty line 
     for a family of the size involved.

       ``(ii) Special rule for taxpayers under 133 percent of 
     poverty line.--If a taxpayer's household income for the 
     taxable year is in excess of 100 percent, but not more than 
     133 percent, of the poverty line for a family of the size 
     involved, the taxpayer's applicable percentage shall be 2 
     percent.
       ``(iii) Indexing.--In the case of taxable years beginning 
     in any calendar year after 2014, the Secretary shall adjust 
     the initial and final applicable percentages under clause 
     (i), and the 2 percent under clause (ii), for the calendar 
     year to reflect the excess of the rate of premium growth 
     between the preceding calendar year and 2013 over the rate of 
     income growth for such period.
       ``(B) Applicable second lowest cost silver plan.--The 
     applicable second lowest cost silver plan with respect to any 
     applicable taxpayer is the second lowest cost silver plan of 
     the individual market in the rating area in which the 
     taxpayer resides which--
       ``(i) is offered through the same Exchange through which 
     the qualified health plans taken into account under paragraph 
     (2)(A) were offered, and
       ``(ii) provides--

       ``(I) self-only coverage in the case of an applicable 
     taxpayer--

       ``(aa) whose tax for the taxable year is determined under 
     section 1(c) (relating to unmarried individuals other than 
     surviving spouses and heads of households) and who is not 
     allowed a deduction under section 151 for the taxable year 
     with respect to a dependent, or
       ``(bb) who is not described in item (aa) but who purchases 
     only self-only coverage, and

       ``(II) family coverage in the case of any other applicable 
     taxpayer.

     If a taxpayer files a joint return and no credit is allowed 
     under this section with respect to 1 of the spouses by reason 
     of subsection (e), the taxpayer shall be treated as described 
     in clause (ii)(I) unless a deduction is allowed under section 
     151 for the taxable year with respect to a dependent other 
     than either spouse and subsection (e) does not apply to the 
     dependent.
       ``(C) Adjusted monthly premium.--The adjusted monthly 
     premium for an applicable second lowest cost silver plan is 
     the monthly premium which would have been charged (for the 
     rating area with respect to which the premiums under 
     paragraph (2)(A) were determined) for the plan if each 
     individual covered under a qualified health plan taken into 
     account under paragraph (2)(A) were covered by such silver 
     plan and the premium was adjusted only for the age of each 
     such individual in the manner allowed under section 2701 of 
     the Public Health Service Act. In the case of a State 
     participating in the wellness discount demonstration project 
     under section 2705(d) of the Public Health Service Act, the 
     adjusted monthly premium shall be determined without regard 
     to any premium discount or rebate under such project.
       ``(D) Additional benefits.--If--
       ``(i) a qualified health plan under section 1302(b)(5) of 
     the Patient Protection and Affordable Care Act offers 
     benefits in addition to the essential health benefits 
     required to be provided by the plan, or
       ``(ii) a State requires a qualified health plan under 
     section 1311(d)(3)(B) of such Act to cover benefits in 
     addition to the essential health benefits required to be 
     provided by the plan,

     the portion of the premium for the plan properly allocable 
     (under rules prescribed by the Secretary of Health and Human 
     Services) to such additional benefits shall not be taken into 
     account in determining either the monthly premium or the 
     adjusted monthly premium under paragraph (2).
       ``(E) Special rule for pediatric dental coverage.--For 
     purposes of determining the amount of any monthly premium, if 
     an individual enrolls in both a qualified health plan and a 
     plan described in section 1311(d)(2)(B)(ii)(I) of the Patient 
     Protection and Affordable Care Act for any plan year, the 
     portion of the premium for the plan described in such section 
     that (under regulations prescribed by the Secretary) is 
     properly allocable to pediatric dental benefits which are 
     included in the essential health benefits required to be 
     provided by a qualified health plan under section 
     1302(b)(1)(J) of such Act shall be treated as a premium 
     payable for a qualified health plan.
       ``(c) Definition and Rules Relating to Applicable 
     Taxpayers, Coverage Months, and Qualified Health Plan.--For 
     purposes of this section--
       ``(1) Applicable taxpayer.--
       ``(A) In general.--The term `applicable taxpayer' means, 
     with respect to any taxable year, a taxpayer whose household 
     income for the taxable year exceeds 100 percent but does not 
     exceed 400 percent of an amount equal to the poverty line for 
     a family of the size involved.
       ``(B) Special rule for certain individuals lawfully present 
     in the united states.--If--
       ``(i) a taxpayer has a household income which is not 
     greater than 100 percent of an amount equal to the poverty 
     line for a family of the size involved, and
       ``(ii) the taxpayer is an alien lawfully present in the 
     United States, but is not eligible for the medicaid program 
     under title XIX of the Social Security Act by reason of such 
     alien status,

     the taxpayer shall, for purposes of the credit under this 
     section, be treated as an applicable taxpayer with a 
     household income which is equal to 100 percent of the poverty 
     line for a family of the size involved.
       ``(C) Married couples must file joint return.--If the 
     taxpayer is married (within the meaning of section 7703) at 
     the close of the taxable year, the taxpayer shall be treated 
     as an applicable taxpayer only if the taxpayer and the 
     taxpayer's spouse file a joint return for the taxable year.
       ``(D) Denial of credit to dependents.--No credit shall be 
     allowed under this section to any individual with respect to 
     whom a deduction under section 151 is allowable to another 
     taxpayer for a taxable year beginning in the calendar year in 
     which such individual's taxable year begins.
       ``(2) Coverage month.--For purposes of this subsection--
       ``(A) In general.--The term `coverage month' means, with 
     respect to an applicable taxpayer, any month if--
       ``(i) as of the first day of such month the taxpayer, the 
     taxpayer's spouse, or any dependent of the taxpayer is 
     covered by a qualified health plan described in subsection 
     (b)(2)(A) that was enrolled in through an Exchange 
     established by the State under section 1311 of the Patient 
     Protection and Affordable Care Act, and
       ``(ii) the premium for coverage under such plan for such 
     month is paid by the taxpayer (or through advance payment of 
     the credit under subsection (a) under section 1412 of the 
     Patient Protection and Affordable Care Act).
       ``(B) Exception for minimum essential coverage.--
       ``(i) In general.--The term `coverage month' shall not 
     include any month with respect to an individual if for such 
     month the individual is eligible for minimum essential 
     coverage other than eligibility for coverage described in 
     section 5000A(f)(1)(C) (relating to coverage in the 
     individual market).

[[Page 4230]]

       ``(ii) Minimum essential coverage.--The term `minimum 
     essential coverage' has the meaning given such term by 
     section 5000A(f).
       ``(C) Special rule for employer-sponsored minimum essential 
     coverage.--For purposes of subparagraph (B)--
       ``(i) Coverage must be affordable.--Except as provided in 
     clause (iii), an employee shall not be treated as eligible 
     for minimum essential coverage if such coverage--

       ``(I) consists of an eligible employer-sponsored plan (as 
     defined in section 5000A(f)(2)), and
       ``(II) the employee's required contribution (within the 
     meaning of section 5000A(e)(1)(B)) with respect to the plan 
     exceeds 9.8 percent of the applicable taxpayer's household 
     income.

     This clause shall also apply to an individual who is eligible 
     to enroll in the plan by reason of a relationship the 
     individual bears to the employee.
       ``(ii) Coverage must provide minimum value.--Except as 
     provided in clause (iii), an employee shall not be treated as 
     eligible for minimum essential coverage if such coverage 
     consists of an eligible employer-sponsored plan (as defined 
     in section 5000A(f)(2)) and the plan's share of the total 
     allowed costs of benefits provided under the plan is less 
     than 60 percent of such costs.
       ``(iii) Employee or family must not be covered under 
     employer plan.--Clauses (i) and (ii) shall not apply if the 
     employee (or any individual described in the last sentence of 
     clause (i)) is covered under the eligible employer-sponsored 
     plan or the grandfathered health plan.
       ``(iv) Indexing.--In the case of plan years beginning in 
     any calendar year after 2014, the Secretary shall adjust the 
     9.8 percent under clause (i)(II) in the same manner as the 
     percentages are adjusted under subsection (b)(3)(A)(ii).
       ``(3) Definitions and other rules.--
       ``(A) Qualified health plan.--The term `qualified health 
     plan' has the meaning given such term by section 1301(a) of 
     the Patient Protection and Affordable Care Act, except that 
     such term shall not include a qualified health plan which is 
     a catastrophic plan described in section 1302(e) of such Act.
       ``(B) Grandfathered health plan.--The term `grandfathered 
     health plan' has the meaning given such term by section 1251 
     of the Patient Protection and Affordable Care Act.
       ``(d) Terms Relating to Income and Families.--For purposes 
     of this section--
       ``(1) Family size.--The family size involved with respect 
     to any taxpayer shall be equal to the number of individuals 
     for whom the taxpayer is allowed a deduction under section 
     151 (relating to allowance of deduction for personal 
     exemptions) for the taxable year.
       ``(2) Household income.--
       ``(A) Household income.--The term `household income' means, 
     with respect to any taxpayer, an amount equal to the sum of--
       ``(i) the modified gross income of the taxpayer, plus
       ``(ii) the aggregate modified gross incomes of all other 
     individuals who--

       ``(I) were taken into account in determining the taxpayer's 
     family size under paragraph (1), and
       ``(II) were required to file a return of tax imposed by 
     section 1 for the taxable year.

       ``(B) Modified gross income.--The term `modified gross 
     income' means gross income--
       ``(i) decreased by the amount of any deduction allowable 
     under paragraph (1), (3), (4), or (10) of section 62(a),
       ``(ii) increased by the amount of interest received or 
     accrued during the taxable year which is exempt from tax 
     imposed by this chapter, and
       ``(iii) determined without regard to sections 911, 931, and 
     933.
       ``(3) Poverty line.--
       ``(A) In general.--The term `poverty line' has the meaning 
     given that term in section 2110(c)(5) of the Social Security 
     Act (42 U.S.C. 1397jj(c)(5)).
       ``(B) Poverty line used.--In the case of any qualified 
     health plan offered through an Exchange for coverage during a 
     taxable year beginning in a calendar year, the poverty line 
     used shall be the most recently published poverty line as of 
     the 1st day of the regular enrollment period for coverage 
     during such calendar year.
       ``(e) Rules for Individuals Not Lawfully Present.--
       ``(1) In general.--If 1 or more individuals for whom a 
     taxpayer is allowed a deduction under section 151 (relating 
     to allowance of deduction for personal exemptions) for the 
     taxable year (including the taxpayer or his spouse) are 
     individuals who are not lawfully present--
       ``(A) the aggregate amount of premiums otherwise taken into 
     account under clauses (i) and (ii) of subsection (b)(2)(A) 
     shall be reduced by the portion (if any) of such premiums 
     which is attributable to such individuals, and
       ``(B) for purposes of applying this section, the 
     determination as to what percentage a taxpayer's household 
     income bears to the poverty level for a family of the size 
     involved shall be made under one of the following methods:
       ``(i) A method under which--

       ``(I) the taxpayer's family size is determined by not 
     taking such individuals into account, and
       ``(II) the taxpayer's household income is equal to the 
     product of the taxpayer's household income (determined 
     without regard to this subsection) and a fraction--

       ``(aa) the numerator of which is the poverty line for the 
     taxpayer's family size determined after application of 
     subclause (I), and
       ``(bb) the denominator of which is the poverty line for the 
     taxpayer's family size determined without regard to subclause 
     (I).
       ``(ii) A comparable method reaching the same result as the 
     method under clause (i).
       ``(2) Lawfully present.--For purposes of this section, an 
     individual shall be treated as lawfully present only if the 
     individual is, and is reasonably expected to be for the 
     entire period of enrollment for which the credit under this 
     section is being claimed, a citizen or national of the United 
     States or an alien lawfully present in the United States.
       ``(3) Secretarial authority.--The Secretary of Health and 
     Human Services, in consultation with the Secretary, shall 
     prescribe rules setting forth the methods by which 
     calculations of family size and household income are made for 
     purposes of this subsection. Such rules shall be designed to 
     ensure that the least burden is placed on individuals 
     enrolling in qualified health plans through an Exchange and 
     taxpayers eligible for the credit allowable under this 
     section.
       ``(f) Reconciliation of Credit and Advance Credit.--
       ``(1) In general.--The amount of the credit allowed under 
     this section for any taxable year shall be reduced (but not 
     below zero) by the amount of any advance payment of such 
     credit under section 1412 of the Patient Protection and 
     Affordable Care Act.
       ``(2) Excess advance payments.--
       ``(A) In general.--If the advance payments to a taxpayer 
     under section 1412 of the Patient Protection and Affordable 
     Care Act for a taxable year exceed the credit allowed by this 
     section (determined without regard to paragraph (1)), the tax 
     imposed by this chapter for the taxable year shall be 
     increased by the amount of such excess.
       ``(B) Limitation on increase where income less than 400 
     percent of poverty line.--
       ``(i) In general.--In the case of an applicable taxpayer 
     whose household income is less than 400 percent of the 
     poverty line for the size of the family involved for the 
     taxable year, the amount of the increase under subparagraph 
     (A) shall in no event exceed $400 ($250 in the case of a 
     taxpayer whose tax is determined under section 1(c) for the 
     taxable year).
       ``(ii) Indexing of amount.--In the case of any calendar 
     year beginning after 2014, each of the dollar amounts under 
     clause (i) shall be increased by an amount equal to--

       ``(I) such dollar amount, multiplied by
       ``(II) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2013' for `calendar year 1992' in 
     subparagraph (B) thereof.

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       ``(g) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary to carry out the provisions 
     of this section, including regulations which provide for--
       ``(1) the coordination of the credit allowed under this 
     section with the program for advance payment of the credit 
     under section 1412 of the Patient Protection and Affordable 
     Care Act, and
       ``(2) the application of subsection (f) where the filing 
     status of the taxpayer for a taxable year is different from 
     such status used for determining the advance payment of the 
     credit.''.
       (b) Disallowance of Deduction.--Section 280C of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new subsection:
       ``(g) Credit for Health Insurance Premiums.--No deduction 
     shall be allowed for the portion of the premiums paid by the 
     taxpayer for coverage of 1 or more individuals under a 
     qualified health plan which is equal to the amount of the 
     credit determined for the taxable year under section 36B(a) 
     with respect to such premiums.''.
       (c) Study on Affordable Coverage.--
       (1) Study and report.--
       (A) In general.--Not later than 5 years after the date of 
     the enactment of this Act, the Comptroller General shall 
     conduct a study on the affordability of health insurance 
     coverage, including--
       (i) the impact of the tax credit for qualified health 
     insurance coverage of individuals under section 36B of the 
     Internal Revenue Code of 1986 and the tax credit for employee 
     health insurance expenses of small employers under section 
     45R of such Code on maintaining and expanding the health 
     insurance coverage of individuals;
       (ii) the availability of affordable health benefits plans, 
     including a study of whether the percentage of household 
     income used for purposes of section 36B(c)(2)(C) of the 
     Internal Revenue Code of 1986 (as added by this section) is 
     the appropriate level for determining whether employer-
     provided coverage is affordable for an employee and whether 
     such level may be lowered without significantly increasing 
     the costs to the Federal Government and reducing employer-
     provided coverage; and
       (iii) the ability of individuals to maintain essential 
     health benefits coverage (as defined in section 5000A(f) of 
     the Internal Revenue Code of 1986).
       (B) Report.--The Comptroller General shall submit to the 
     appropriate committees of Congress a report on the study 
     conducted under subparagraph (A), together with legislative 
     recommendations relating to the matters studied under such 
     subparagraph.
       (2) Appropriate committees of congress.--In this 
     subsection, the term ``appropriate committees of Congress'' 
     means the Committee on Ways and Means, the Committee on 
     Education and Labor, and the Committee on Energy and

[[Page 4231]]

     Commerce of the House of Representatives and the Committee on 
     Finance and the Committee on Health, Education, Labor and 
     Pensions of the Senate.
       (d) Conforming Amendments.--
       (1) Paragraph (2) of section 1324(b) of title 31, United 
     States Code, is amended by inserting ``36B,'' after ``36A,''.
       (2) The table of sections for subpart C of part IV of 
     subchapter A of chapter 1 of the Internal Revenue Code of 
     1986 is amended by inserting after the item relating to 
     section 36A the following new item:

``Sec. 36B. Refundable credit for coverage under a qualified health 
              plan.''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after December 31, 2013.

     SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN 
                   QUALIFIED HEALTH PLANS.

       (a) In General.--In the case of an eligible insured 
     enrolled in a qualified health plan--
       (1) the Secretary shall notify the issuer of the plan of 
     such eligibility; and
       (2) the issuer shall reduce the cost-sharing under the plan 
     at the level and in the manner specified in subsection (c).
       (b) Eligible Insured.--In this section, the term ``eligible 
     insured'' means an individual--
       (1) who enrolls in a qualified health plan in the silver 
     level of coverage in the individual market offered through an 
     Exchange; and
       (2) whose household income exceeds 100 percent but does not 
     exceed 400 percent of the poverty line for a family of the 
     size involved.
     In the case of an individual described in section 
     36B(c)(1)(B) of the Internal Revenue Code of 1986, the 
     individual shall be treated as having household income equal 
     to 100 percent for purposes of applying this section.
       (c) Determination of Reduction in Cost-sharing.--
       (1) Reduction in out-of-pocket limit.--
       (A) In general.--The reduction in cost-sharing under this 
     subsection shall first be achieved by reducing the applicable 
     out-of pocket limit under section 1302(c)(1) in the case of--
       (i) an eligible insured whose household income is more than 
     100 percent but not more than 200 percent of the poverty line 
     for a family of the size involved, by two-thirds;
       (ii) an eligible insured whose household income is more 
     than 200 percent but not more than 300 percent of the poverty 
     line for a family of the size involved, by one-half; and
       (iii) an eligible insured whose household income is more 
     than 300 percent but not more than 400 percent of the poverty 
     line for a family of the size involved, by one-third.
       (B) Coordination with actuarial value limits.--
       (i) In general.--The Secretary shall ensure the reduction 
     under this paragraph shall not result in an increase in the 
     plan's share of the total allowed costs of benefits provided 
     under the plan above--

       (I) 90 percent in the case of an eligible insured described 
     in paragraph (2)(A);
       (II) 80 percent in the case of an eligible insured 
     described in paragraph (2)(B); and
       (III) 70 percent in the case of an eligible insured 
     described in clause (ii) or (iii) of subparagraph (A).

       (ii) Adjustment.--The Secretary shall adjust the out-of 
     pocket limits under paragraph (1) if necessary to ensure that 
     such limits do not cause the respective actuarial values to 
     exceed the levels specified in clause (i).
       (2) Additional reduction for lower income insureds.--The 
     Secretary shall establish procedures under which the issuer 
     of a qualified health plan to which this section applies 
     shall further reduce cost-sharing under the plan in a manner 
     sufficient to--
       (A) in the case of an eligible insured whose household 
     income is not less than 100 percent but not more than 150 
     percent of the poverty line for a family of the size 
     involved, increase the plan's share of the total allowed 
     costs of benefits provided under the plan to 90 percent of 
     such costs; and
       (B) in the case of an eligible insured whose household 
     income is more than 150 percent but not more than 200 percent 
     of the poverty line for a family of the size involved, 
     increase the plan's share of the total allowed costs of 
     benefits provided under the plan to 80 percent of such costs.
       (3) Methods for reducing cost-sharing.--
       (A) In general.--An issuer of a qualified health plan 
     making reductions under this subsection shall notify the 
     Secretary of such reductions and the Secretary shall make 
     periodic and timely payments to the issuer equal to the value 
     of the reductions.
       (B) Capitated payments.--The Secretary may establish a 
     capitated payment system to carry out the payment of cost-
     sharing reductions under this section. Any such system shall 
     take into account the value of the reductions and make 
     appropriate risk adjustments to such payments.
       (4) Additional benefits.--If a qualified health plan under 
     section 1302(b)(5) offers benefits in addition to the 
     essential health benefits required to be provided by the 
     plan, or a State requires a qualified health plan under 
     section 1311(d)(3)(B) to cover benefits in addition to the 
     essential health benefits required to be provided by the 
     plan, the reductions in cost-sharing under this section shall 
     not apply to such additional benefits.
       (5) Special rule for pediatric dental plans.--If an 
     individual enrolls in both a qualified health plan and a plan 
     described in section 1311(d)(2)(B)(ii)(I) for any plan year, 
     subsection (a) shall not apply to that portion of any 
     reduction in cost-sharing under subsection (c) that (under 
     regulations prescribed by the Secretary) is properly 
     allocable to pediatric dental benefits which are included in 
     the essential health benefits required to be provided by a 
     qualified health plan under section 1302(b)(1)(J).
       (d) Special Rules for Indians.--
       (1) Indians under 300 percent of poverty.--If an individual 
     enrolled in any qualified health plan in the individual 
     market through an Exchange is an Indian (as defined in 
     section 4(d) of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450b(d))) whose household income is 
     not more than 300 percent of the poverty line for a family of 
     the size involved, then, for purposes of this section--
       (A) such individual shall be treated as an eligible 
     insured; and
       (B) the issuer of the plan shall eliminate any cost-sharing 
     under the plan.
       (2) Items or services furnished through indian health 
     providers.--If an Indian (as so defined) enrolled in a 
     qualified health plan is furnished an item or service 
     directly by the Indian Health Service, an Indian Tribe, 
     Tribal Organization, or Urban Indian Organization or through 
     referral under contract health services--
       (A) no cost-sharing under the plan shall be imposed under 
     the plan for such item or service; and
       (B) the issuer of the plan shall not reduce the payment to 
     any such entity for such item or service by the amount of any 
     cost-sharing that would be due from the Indian but for 
     subparagraph (A).
       (3) Payment.--The Secretary shall pay to the issuer of a 
     qualified health plan the amount necessary to reflect the 
     increase in actuarial value of the plan required by reason of 
     this subsection.
       (e) Rules for Individuals Not Lawfully Present.--
       (1) In general.--If an individual who is an eligible 
     insured is not lawfully present--
       (A) no cost-sharing reduction under this section shall 
     apply with respect to the individual; and
       (B) for purposes of applying this section, the 
     determination as to what percentage a taxpayer's household 
     income bears to the poverty level for a family of the size 
     involved shall be made under one of the following methods:
       (i) A method under which--

       (I) the taxpayer's family size is determined by not taking 
     such individuals into account, and
       (II) the taxpayer's household income is equal to the 
     product of the taxpayer's household income (determined 
     without regard to this subsection) and a fraction--

       (aa) the numerator of which is the poverty line for the 
     taxpayer's family size determined after application of 
     subclause (I), and
       (bb) the denominator of which is the poverty line for the 
     taxpayer's family size determined without regard to subclause 
     (I).
       (ii) A comparable method reaching the same result as the 
     method under clause (i).
       (2) Lawfully present.--For purposes of this section, an 
     individual shall be treated as lawfully present only if the 
     individual is, and is reasonably expected to be for the 
     entire period of enrollment for which the cost-sharing 
     reduction under this section is being claimed, a citizen or 
     national of the United States or an alien lawfully present in 
     the United States.
       (3) Secretarial authority.--The Secretary, in consultation 
     with the Secretary of the Treasury, shall prescribe rules 
     setting forth the methods by which calculations of family 
     size and household income are made for purposes of this 
     subsection. Such rules shall be designed to ensure that the 
     least burden is placed on individuals enrolling in qualified 
     health plans through an Exchange and taxpayers eligible for 
     the credit allowable under this section.
       (f) Definitions and Special Rules.--In this section:
       (1) In general.--Any term used in this section which is 
     also used in section 36B of the Internal Revenue Code of 1986 
     shall have the meaning given such term by such section.
       (2) Limitations on reduction.--No cost-sharing reduction 
     shall be allowed under this section with respect to coverage 
     for any month unless the month is a coverage month with 
     respect to which a credit is allowed to the insured (or an 
     applicable taxpayer on behalf of the insured) under section 
     36B of such Code.
       (3) Data used for eligibility.--Any determination under 
     this section shall be made on the basis of the taxable year 
     for which the advance determination is made under section 
     1412 and not the taxable year for which the credit under 
     section 36B of such Code is allowed.

                 Subpart B--Eligibility Determinations

     SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY FOR 
                   EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS AND 
                   REDUCED COST-SHARING, AND INDIVIDUAL 
                   RESPONSIBILITY EXEMPTIONS.

       (a) Establishment of Program.--The Secretary shall 
     establish a program meeting the requirements of this section 
     for determining--
       (1) whether an individual who is to be covered in the 
     individual market by a qualified health plan offered through 
     an Exchange, or who is claiming a premium tax credit or 
     reduced cost-sharing, meets the requirements of sections 
     1312(f)(3), 1402(e), and 1412(d) of this title and section 
     36B(e) of the Internal Revenue Code of 1986 that the 
     individual be a citizen or national of the United States or 
     an alien lawfully present in the United States;
       (2) in the case of an individual claiming a premium tax 
     credit or reduced cost-sharing under section 36B of such Code 
     or section 1402--

[[Page 4232]]

       (A) whether the individual meets the income and coverage 
     requirements of such sections; and
       (B) the amount of the tax credit or reduced cost-sharing;
       (3) whether an individual's coverage under an employer-
     sponsored health benefits plan is treated as unaffordable 
     under sections 36B(c)(2)(C) and 5000A(e)(2); and
       (4) whether to grant a certification under section 
     1311(d)(4)(H) attesting that, for purposes of the individual 
     responsibility requirement under section 5000A of the 
     Internal Revenue Code of 1986, an individual is entitled to 
     an exemption from either the individual responsibility 
     requirement or the penalty imposed by such section.
       (b) Information Required To Be Provided by Applicants.--
       (1) In general.--An applicant for enrollment in a qualified 
     health plan offered through an Exchange in the individual 
     market shall provide--
       (A) the name, address, and date of birth of each individual 
     who is to be covered by the plan (in this subsection referred 
     to as an ``enrollee''); and
       (B) the information required by any of the following 
     paragraphs that is applicable to an enrollee.
       (2) Citizenship or immigration status.--The following 
     information shall be provided with respect to every enrollee:
       (A) In the case of an enrollee whose eligibility is based 
     on an attestation of citizenship of the enrollee, the 
     enrollee's social security number.
       (B) In the case of an individual whose eligibility is based 
     on an attestation of the enrollee's immigration status, the 
     enrollee's social security number (if applicable) and such 
     identifying information with respect to the enrollee's 
     immigration status as the Secretary, after consultation with 
     the Secretary of Homeland Security, determines appropriate.
       (3) Eligibility and amount of tax credit or reduced cost-
     sharing.--In the case of an enrollee with respect to whom a 
     premium tax credit or reduced cost-sharing under section 36B 
     of such Code or section 1402 is being claimed, the following 
     information:
       (A) Information regarding income and family size.--The 
     information described in section 6103(l)(21) for the taxable 
     year ending with or within the second calendar year preceding 
     the calendar year in which the plan year begins.
       (B) Changes in circumstances.--The information described in 
     section 1412(b)(2), including information with respect to 
     individuals who were not required to file an income tax 
     return for the taxable year described in subparagraph (A) or 
     individuals who experienced changes in marital status or 
     family size or significant reductions in income.
       (4) Employer-sponsored coverage.--In the case of an 
     enrollee with respect to whom eligibility for a premium tax 
     credit under section 36B of such Code or cost-sharing 
     reduction under section 1402 is being established on the 
     basis that the enrollee's (or related individual's) employer 
     is not treated under section 36B(c)(2)(C) of such Code as 
     providing minimum essential coverage or affordable minimum 
     essential coverage, the following information:
       (A) The name, address, and employer identification number 
     (if available) of the employer.
       (B) Whether the enrollee or individual is a full-time 
     employee and whether the employer provides such minimum 
     essential coverage.
       (C) If the employer provides such minimum essential 
     coverage, the lowest cost option for the enrollee's or 
     individual's enrollment status and the enrollee's or 
     individual's required contribution (within the meaning of 
     section 5000A(e)(1)(B) of such Code) under the employer-
     sponsored plan.
       (D) If an enrollee claims an employer's minimum essential 
     coverage is unaffordable, the information described in 
     paragraph (3).

     If an enrollee changes employment or obtains additional 
     employment while enrolled in a qualified health plan for 
     which such credit or reduction is allowed, the enrollee shall 
     notify the Exchange of such change or additional employment 
     and provide the information described in this paragraph with 
     respect to the new employer.
       (5) Exemptions from individual responsibility 
     requirements.--In the case of an individual who is seeking an 
     exemption certificate under section 1311(d)(4)(H) from any 
     requirement or penalty imposed by section 5000A, the 
     following information:
       (A) In the case of an individual seeking exemption based on 
     the individual's status as a member of an exempt religious 
     sect or division, as a member of a health care sharing 
     ministry, as an Indian, or as an individual eligible for a 
     hardship exemption, such information as the Secretary shall 
     prescribe.
       (B) In the case of an individual seeking exemption based on 
     the lack of affordable coverage or the individual's status as 
     a taxpayer with household income less than 100 percent of the 
     poverty line, the information described in paragraphs (3) and 
     (4), as applicable.
       (c) Verification of Information Contained in Records of 
     Specific Federal Officials.--
       (1) Information transferred to secretary.--An Exchange 
     shall submit the information provided by an applicant under 
     subsection (b) to the Secretary for verification in 
     accordance with the requirements of this subsection and 
     subsection (d).
       (2) Citizenship or immigration status.--
       (A) Commissioner of social security.--The Secretary shall 
     submit to the Commissioner of Social Security the following 
     information for a determination as to whether the information 
     provided is consistent with the information in the records of 
     the Commissioner:
       (i) The name, date of birth, and social security number of 
     each individual for whom such information was provided under 
     subsection (b)(2).
       (ii) The attestation of an individual that the individual 
     is a citizen.
       (B) Secretary of homeland security.--
       (i) In general.--In the case of an individual--

       (I) who attests that the individual is an alien lawfully 
     present in the United States; or
       (II) who attests that the individual is a citizen but with 
     respect to whom the Commissioner of Social Security has 
     notified the Secretary under subsection (e)(3) that the 
     attestation is inconsistent with information in the records 
     maintained by the Commissioner;

     the Secretary shall submit to the Secretary of Homeland 
     Security the information described in clause (ii) for a 
     determination as to whether the information provided is 
     consistent with the information in the records of the 
     Secretary of Homeland Security.
       (ii) Information.--The information described in clause (ii) 
     is the following:

       (I) The name, date of birth, and any identifying 
     information with respect to the individual's immigration 
     status provided under subsection (b)(2).
       (II) The attestation that the individual is an alien 
     lawfully present in the United States or in the case of an 
     individual described in clause (i)(II), the attestation that 
     the individual is a citizen.

       (3) Eligibility for tax credit and cost-sharing 
     reduction.--The Secretary shall submit the information 
     described in subsection (b)(3)(A) provided under paragraph 
     (3), (4), or (5) of subsection (b) to the Secretary of the 
     Treasury for verification of household income and family size 
     for purposes of eligibility.
       (4) Methods.--
       (A) In general.--The Secretary, in consultation with the 
     Secretary of the Treasury, the Secretary of Homeland 
     Security, and the Commissioner of Social Security, shall 
     provide that verifications and determinations under this 
     subsection shall be done--
       (i) through use of an on-line system or otherwise for the 
     electronic submission of, and response to, the information 
     submitted under this subsection with respect to an applicant; 
     or
       (ii) by determining the consistency of the information 
     submitted with the information maintained in the records of 
     the Secretary of the Treasury, the Secretary of Homeland 
     Security, or the Commissioner of Social Security through such 
     other method as is approved by the Secretary.
       (B) Flexibility.--The Secretary may modify the methods used 
     under the program established by this section for the 
     Exchange and verification of information if the Secretary 
     determines such modifications would reduce the administrative 
     costs and burdens on the applicant, including allowing an 
     applicant to request the Secretary of the Treasury to provide 
     the information described in paragraph (3) directly to the 
     Exchange or to the Secretary. The Secretary shall not make 
     any such modification unless the Secretary determines that 
     any applicable requirements under this section and section 
     6103 of the Internal Revenue Code of 1986 with respect to the 
     confidentiality, disclosure, maintenance, or use of 
     information will be met.
       (d) Verification by Secretary.--In the case of information 
     provided under subsection (b) that is not required under 
     subsection (c) to be submitted to another person for 
     verification, the Secretary shall verify the accuracy of such 
     information in such manner as the Secretary determines 
     appropriate, including delegating responsibility for 
     verification to the Exchange.
       (e) Actions Relating to Verification.--
       (1) In general.--Each person to whom the Secretary provided 
     information under subsection (c) shall report to the 
     Secretary under the method established under subsection 
     (c)(4) the results of its verification and the Secretary 
     shall notify the Exchange of such results. Each person to 
     whom the Secretary provided information under subsection (d) 
     shall report to the Secretary in such manner as the Secretary 
     determines appropriate.
       (2) Verification.--
       (A) Eligibility for enrollment and premium tax credits and 
     cost-sharing reductions.--If information provided by an 
     applicant under paragraphs (1), (2), (3), and (4) of 
     subsection (b) is verified under subsections (c) and (d)--
       (i) the individual's eligibility to enroll through the 
     Exchange and to apply for premium tax credits and cost-
     sharing reductions shall be satisfied; and
       (ii) the Secretary shall, if applicable, notify the 
     Secretary of the Treasury under section 1412(c) of the amount 
     of any advance payment to be made.
       (B) Exemption from individual responsibility.--If 
     information provided by an applicant under subsection (b)(5) 
     is verified under subsections (c) and (d), the Secretary 
     shall issue the certification of exemption described in 
     section 1311(d)(4)(H).
       (3) Inconsistencies involving attestation of citizenship or 
     lawful presence.--If the information provided by any 
     applicant under subsection (b)(2) is inconsistent with 
     information in the records maintained by the Commissioner of 
     Social Security or Secretary of Homeland Security, whichever 
     is applicable, the applicant's eligibility will be determined 
     in the same manner

[[Page 4233]]

     as an individual's eligibility under the medicaid program is 
     determined under section 1902(ee) of the Social Security Act 
     (as in effect on January 1, 2010).
       (4) Inconsistencies involving other information.--
       (A) In general.--If the information provided by an 
     applicant under subsection (b) (other than subsection (b)(2)) 
     is inconsistent with information in the records maintained by 
     persons under subsection (c) or is not verified under 
     subsection (d), the Secretary shall notify the Exchange and 
     the Exchange shall take the following actions:
       (i) Reasonable effort.--The Exchange shall make a 
     reasonable effort to identify and address the causes of such 
     inconsistency, including through typographical or other 
     clerical errors, by contacting the applicant to confirm the 
     accuracy of the information, and by taking such additional 
     actions as the Secretary, through regulation or other 
     guidance, may identify.
       (ii) Notice and opportunity to correct.--In the case the 
     inconsistency or inability to verify is not resolved under 
     subparagraph (A), the Exchange shall--

       (I) notify the applicant of such fact;
       (II) provide the applicant an opportunity to either present 
     satisfactory documentary evidence or resolve the 
     inconsistency with the person verifying the information under 
     subsection (c) or (d) during the 90-day period beginning the 
     date on which the notice required under subclause (I) is sent 
     to the applicant.

     The Secretary may extend the 90-day period under subclause 
     (II) for enrollments occurring during 2014.
       (B) Specific actions not involving citizenship or lawful 
     presence.--
       (i) In general.--Except as provided in paragraph (3), the 
     Exchange shall, during any period before the close of the 
     period under subparagraph (A)(ii)(II), make any determination 
     under paragraphs (2), (3), and (4) of subsection (a) on the 
     basis of the information contained on the application.
       (ii) Eligibility or amount of credit or reduction.--If an 
     inconsistency involving the eligibility for, or amount of, 
     any premium tax credit or cost-sharing reduction is 
     unresolved under this subsection as of the close of the 
     period under subparagraph (A)(ii)(II), the Exchange shall 
     notify the applicant of the amount (if any) of the credit or 
     reduction that is determined on the basis of the records 
     maintained by persons under subsection (c).
       (iii) Employer affordability.--If the Secretary notifies an 
     Exchange that an enrollee is eligible for a premium tax 
     credit under section 36B of such Code or cost-sharing 
     reduction under section 1402 because the enrollee's (or 
     related individual's) employer does not provide minimum 
     essential coverage through an employer-sponsored plan or that 
     the employer does provide that coverage but it is not 
     affordable coverage, the Exchange shall notify the employer 
     of such fact and that the employer may be liable for the 
     payment assessed under section 4980H of such Code.
       (iv) Exemption.--In any case where the inconsistency 
     involving, or inability to verify, information provided under 
     subsection (b)(5) is not resolved as of the close of the 
     period under subparagraph (A)(ii)(II), the Exchange shall 
     notify an applicant that no certification of exemption from 
     any requirement or payment under section 5000A of such Code 
     will be issued.
       (C) Appeals process.--The Exchange shall also notify each 
     person receiving notice under this paragraph of the appeals 
     processes established under subsection (f).
       (f) Appeals and Redeterminations.--
       (1) In general.--The Secretary, in consultation with the 
     Secretary of the Treasury, the Secretary of Homeland 
     Security, and the Commissioner of Social Security, shall 
     establish procedures by which the Secretary or one of such 
     other Federal officers--
       (A) hears and makes decisions with respect to appeals of 
     any determination under subsection (e); and
       (B) redetermines eligibility on a periodic basis in 
     appropriate circumstances.
       (2) Employer liability.--
       (A) In general.--The Secretary shall establish a separate 
     appeals process for employers who are notified under 
     subsection (e)(4)(C) that the employer may be liable for a 
     tax imposed by section 4980H of the Internal Revenue Code of 
     1986 with respect to an employee because of a determination 
     that the employer does not provide minimum essential coverage 
     through an employer-sponsored plan or that the employer does 
     provide that coverage but it is not affordable coverage with 
     respect to an employee. Such process shall provide an 
     employer the opportunity to--
       (i) present information to the Exchange for review of the 
     determination either by the Exchange or the person making the 
     determination, including evidence of the employer-sponsored 
     plan and employer contributions to the plan; and
       (ii) have access to the data used to make the determination 
     to the extent allowable by law.
     Such process shall be in addition to any rights of appeal the 
     employer may have under subtitle F of such Code.
       (B) Confidentiality.--Notwithstanding any provision of this 
     title (or the amendments made by this title) or section 6103 
     of the Internal Revenue Code of 1986, an employer shall not 
     be entitled to any taxpayer return information with respect 
     to an employee for purposes of determining whether the 
     employer is subject to the penalty under section 4980H of 
     such Code with respect to the employee, except that--
       (i) the employer may be notified as to the name of an 
     employee and whether or not the employee's income is above or 
     below the threshold by which the affordability of an 
     employer's health insurance coverage is measured; and
       (ii) this subparagraph shall not apply to an employee who 
     provides a waiver (at such time and in such manner as the 
     Secretary may prescribe) authorizing an employer to have 
     access to the employee's taxpayer return information.
       (g) Confidentiality of Applicant Information.--
       (1) In general.--An applicant for insurance coverage or for 
     a premium tax credit or cost-sharing reduction shall be 
     required to provide only the information strictly necessary 
     to authenticate identity, determine eligibility, and 
     determine the amount of the credit or reduction.
       (2) Receipt of information.--Any person who receives 
     information provided by an applicant under subsection (b) 
     (whether directly or by another person at the request of the 
     applicant), or receives information from a Federal agency 
     under subsection (c), (d), or (e), shall--
       (A) use the information only for the purposes of, and to 
     the extent necessary in, ensuring the efficient operation of 
     the Exchange, including verifying the eligibility of an 
     individual to enroll through an Exchange or to claim a 
     premium tax credit or cost-sharing reduction or the amount of 
     the credit or reduction; and
       (B) not disclose the information to any other person except 
     as provided in this section.
       (h) Penalties.--
       (1) False or fraudulent information.--
       (A) Civil penalty.--
       (i) In general.--If--

       (I) any person fails to provides correct information under 
     subsection (b); and
       (II) such failure is attributable to negligence or 
     disregard of any rules or regulations of the Secretary,

     such person shall be subject, in addition to any other 
     penalties that may be prescribed by law, to a civil penalty 
     of not more than $25,000 with respect to any failures 
     involving an application for a plan year. For purposes of 
     this subparagraph, the terms ``negligence'' and ``disregard'' 
     shall have the same meanings as when used in section 6662 of 
     the Internal Revenue Code of 1986.
       (ii) Reasonable cause exception.--No penalty shall be 
     imposed under clause (i) if the Secretary determines that 
     there was a reasonable cause for the failure and that the 
     person acted in good faith.
       (B) Knowing and willful violations.--Any person who 
     knowingly and willfully provides false or fraudulent 
     information under subsection (b) shall be subject, in 
     addition to any other penalties that may be prescribed by 
     law, to a civil penalty of not more than $250,000.
       (2) Improper use or disclosure of information.--Any person 
     who knowingly and willfully uses or discloses information in 
     violation of subsection (g) shall be subject, in addition to 
     any other penalties that may be prescribed by law, to a civil 
     penalty of not more than $25,000.
       (3) Limitations on liens and levies.--The Secretary (or, if 
     applicable, the Attorney General of the United States) shall 
     not--
       (A) file notice of lien with respect to any property of a 
     person by reason of any failure to pay the penalty imposed by 
     this subsection; or
       (B) levy on any such property with respect to such failure.
       (i) Study of Administration of Employer Responsibility.--
       (1) In general.--The Secretary of Health and Human Services 
     shall, in consultation with the Secretary of the Treasury, 
     conduct a study of the procedures that are necessary to 
     ensure that in the administration of this title and section 
     4980H of the Internal Revenue Code of 1986 (as added by 
     section 1513) that the following rights are protected:
       (A) The rights of employees to preserve their right to 
     confidentiality of their taxpayer return information and 
     their right to enroll in a qualified health plan through an 
     Exchange if an employer does not provide affordable coverage.
       (B) The rights of employers to adequate due process and 
     access to information necessary to accurately determine any 
     payment assessed on employers.
       (2) Report.--Not later than January 1, 2013, the Secretary 
     of Health and Human Services shall report the results of the 
     study conducted under paragraph (1), including any 
     recommendations for legislative changes, to the Committees on 
     Finance and Health, Education, Labor and Pensions of the 
     Senate and the Committees of Education and Labor and Ways and 
     Means of the House of Representatives.

     SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX 
                   CREDITS AND COST-SHARING REDUCTIONS.

       (a) In General.--The Secretary, in consultation with the 
     Secretary of the Treasury, shall establish a program under 
     which--
       (1) upon request of an Exchange, advance determinations are 
     made under section 1411 with respect to the income 
     eligibility of individuals enrolling in a qualified health 
     plan in the individual market through the Exchange for the 
     premium tax credit allowable under section 36B of the 
     Internal Revenue Code of 1986 and the cost-sharing reductions 
     under section 1402;
       (2) the Secretary notifies--
       (A) the Exchange and the Secretary of the Treasury of the 
     advance determinations; and
       (B) the Secretary of the Treasury of the name and employer 
     identification number of each employer with respect to whom 1 
     or more employee of the employer were determined to be 
     eligible for the premium tax credit under section 36B of

[[Page 4234]]

     the Internal Revenue Code of 1986 and the cost-sharing 
     reductions under section 1402 because--
       (i) the employer did not provide minimum essential 
     coverage; or
       (ii) the employer provided such minimum essential coverage 
     but it was determined under section 36B(c)(2)(C) of such Code 
     to either be unaffordable to the employee or not provide the 
     required minimum actuarial value; and
       (3) the Secretary of the Treasury makes advance payments of 
     such credit or reductions to the issuers of the qualified 
     health plans in order to reduce the premiums payable by 
     individuals eligible for such credit.
       (b) Advance Determinations.--
       (1) In general.--The Secretary shall provide under the 
     program established under subsection (a) that advance 
     determination of eligibility with respect to any individual 
     shall be made--
       (A) during the annual open enrollment period applicable to 
     the individual (or such other enrollment period as may be 
     specified by the Secretary); and
       (B) on the basis of the individual's household income for 
     the most recent taxable year for which the Secretary, after 
     consultation with the Secretary of the Treasury, determines 
     information is available.
       (2) Changes in circumstances.--The Secretary shall provide 
     procedures for making advance determinations on the basis of 
     information other than that described in paragraph (1)(B) in 
     cases where information included with an application form 
     demonstrates substantial changes in income, changes in family 
     size or other household circumstances, change in filing 
     status, the filing of an application for unemployment 
     benefits, or other significant changes affecting eligibility, 
     including--
       (A) allowing an individual claiming a decrease of 20 
     percent or more in income, or filing an application for 
     unemployment benefits, to have eligibility for the credit 
     determined on the basis of household income for a later 
     period or on the basis of the individual's estimate of such 
     income for the taxable year; and
       (B) the determination of household income in cases where 
     the taxpayer was not required to file a return of tax imposed 
     by this chapter for the second preceding taxable year.
       (c) Payment of Premium Tax Credits and Cost-sharing 
     Reductions.--
       (1) In general.--The Secretary shall notify the Secretary 
     of the Treasury and the Exchange through which the individual 
     is enrolling of the advance determination under section 1411.
       (2) Premium tax credit.--
       (A) In general.--The Secretary of the Treasury shall make 
     the advance payment under this section of any premium tax 
     credit allowed under section 36B of the Internal Revenue Code 
     of 1986 to the issuer of a qualified health plan on a monthly 
     basis (or such other periodic basis as the Secretary may 
     provide).
       (B) Issuer responsibilities.--An issuer of a qualified 
     health plan receiving an advance payment with respect to an 
     individual enrolled in the plan shall--
       (i) reduce the premium charged the insured for any period 
     by the amount of the advance payment for the period;
       (ii) notify the Exchange and the Secretary of such 
     reduction;
       (iii) include with each billing statement the amount by 
     which the premium for the plan has been reduced by reason of 
     the advance payment; and
       (iv) in the case of any nonpayment of premiums by the 
     insured--

       (I) notify the Secretary of such nonpayment; and
       (II) allow a 3-month grace period for nonpayment of 
     premiums before discontinuing coverage.

       (3) Cost-sharing reductions.--The Secretary shall also 
     notify the Secretary of the Treasury and the Exchange under 
     paragraph (1) if an advance payment of the cost-sharing 
     reductions under section 1402 is to be made to the issuer of 
     any qualified health plan with respect to any individual 
     enrolled in the plan. The Secretary of the Treasury shall 
     make such advance payment at such time and in such amount as 
     the Secretary specifies in the notice.
       (d) No Federal Payments for Individuals Not Lawfully 
     Present.--Nothing in this subtitle or the amendments made by 
     this subtitle allows Federal payments, credits, or cost-
     sharing reductions for individuals who are not lawfully 
     present in the United States.
       (e) State Flexibility.--Nothing in this subtitle or the 
     amendments made by this subtitle shall be construed to 
     prohibit a State from making payments to or on behalf of an 
     individual for coverage under a qualified health plan offered 
     through an Exchange that are in addition to any credits or 
     cost-sharing reductions allowable to the individual under 
     this subtitle and such amendments.

     SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH 
                   AN EXCHANGE AND STATE MEDICAID, CHIP, AND 
                   HEALTH SUBSIDY PROGRAMS.

       (a) In General.--The Secretary shall establish a system 
     meeting the requirements of this section under which 
     residents of each State may apply for enrollment in, receive 
     a determination of eligibility for participation in, and 
     continue participation in, applicable State health subsidy 
     programs. Such system shall ensure that if an individual 
     applying to an Exchange is found through screening to be 
     eligible for medical assistance under the State medicaid plan 
     under title XIX, or eligible for enrollment under a State 
     children's health insurance program (CHIP) under title XXI of 
     such Act, the individual is enrolled for assistance under 
     such plan or program.
       (b) Requirements Relating to Forms and Notice.--
       (1) Requirements relating to forms.--
       (A) In general.--The Secretary shall develop and provide to 
     each State a single, streamlined form that--
       (i) may be used to apply for all applicable State health 
     subsidy programs within the State;
       (ii) may be filed online, in person, by mail, or by 
     telephone;
       (iii) may be filed with an Exchange or with State officials 
     operating one of the other applicable State health subsidy 
     programs; and
       (iv) is structured to maximize an applicant's ability to 
     complete the form satisfactorily, taking into account the 
     characteristics of individuals who qualify for applicable 
     State health subsidy programs.
       (B) State authority to establish form.--A State may develop 
     and use its own single, streamlined form as an alternative to 
     the form developed under subparagraph (A) if the alternative 
     form is consistent with standards promulgated by the 
     Secretary under this section.
       (C) Supplemental eligibility forms.--The Secretary may 
     allow a State to use a supplemental or alternative form in 
     the case of individuals who apply for eligibility that is not 
     determined on the basis of the household income (as defined 
     in section 36B of the Internal Revenue Code of 1986).
       (2) Notice.--The Secretary shall provide that an applicant 
     filing a form under paragraph (1) shall receive notice of 
     eligibility for an applicable State health subsidy program 
     without any need to provide additional information or 
     paperwork unless such information or paperwork is 
     specifically required by law when information provided on the 
     form is inconsistent with data used for the electronic 
     verification under paragraph (3) or is otherwise insufficient 
     to determine eligibility.
       (c) Requirements Relating to Eligibility Based on Data 
     Exchanges.--
       (1) Development of secure interfaces.--Each State shall 
     develop for all applicable State health subsidy programs a 
     secure, electronic interface allowing an exchange of data 
     (including information contained in the application forms 
     described in subsection (b)) that allows a determination of 
     eligibility for all such programs based on a single 
     application. Such interface shall be compatible with the 
     method established for data verification under section 
     1411(c)(4).
       (2) Data matching program.--Each applicable State health 
     subsidy program shall participate in a data matching 
     arrangement for determining eligibility for participation in 
     the program under paragraph (3) that--
       (A) provides access to data described in paragraph (3);
       (B) applies only to individuals who--
       (i) receive assistance from an applicable State health 
     subsidy program; or
       (ii) apply for such assistance--

       (I) by filing a form described in subsection (b); or
       (II) by requesting a determination of eligibility and 
     authorizing disclosure of the information described in 
     paragraph (3) to applicable State health coverage subsidy 
     programs for purposes of determining and establishing 
     eligibility; and

       (C) consistent with standards promulgated by the Secretary, 
     including the privacy and data security safeguards described 
     in section 1942 of the Social Security Act or that are 
     otherwise applicable to such programs.
       (3) Determination of eligibility.--
       (A) In general.--Each applicable State health subsidy 
     program shall, to the maximum extent practicable--
       (i) establish, verify, and update eligibility for 
     participation in the program using the data matching 
     arrangement under paragraph (2); and
       (ii) determine such eligibility on the basis of reliable, 
     third party data, including information described in sections 
     1137, 453(i), and 1942(a) of the Social Security Act, 
     obtained through such arrangement.
       (B) Exception.--This paragraph shall not apply in 
     circumstances with respect to which the Secretary determines 
     that the administrative and other costs of use of the data 
     matching arrangement under paragraph (2) outweigh its 
     expected gains in accuracy, efficiency, and program 
     participation.
       (4) Secretarial standards.--The Secretary shall, after 
     consultation with persons in possession of the data to be 
     matched and representatives of applicable State health 
     subsidy programs, promulgate standards governing the timing, 
     contents, and procedures for data matching described in this 
     subsection. Such standards shall take into account 
     administrative and other costs and the value of data matching 
     to the establishment, verification, and updating of 
     eligibility for applicable State health subsidy programs.
       (d) Administrative Authority.--
       (1) Agreements.--Subject to section 1411 and section 
     6103(l)(21) of the Internal Revenue Code of 1986 and any 
     other requirement providing safeguards of privacy and data 
     integrity, the Secretary may establish model agreements, and 
     enter into agreements, for the sharing of data under this 
     section.
       (2) Authority of exchange to contract out.--Nothing in this 
     section shall be construed to--
       (A) prohibit contractual arrangements through which a State 
     medicaid agency determines eligibility for all applicable 
     State health subsidy programs, but only if such agency 
     complies with the Secretary's requirements ensuring

[[Page 4235]]

     reduced administrative costs, eligibility errors, and 
     disruptions in coverage; or
       (B) change any requirement under title XIX that eligibility 
     for participation in a State's medicaid program must be 
     determined by a public agency.
       (e) Applicable State Health Subsidy Program.--In this 
     section, the term ``applicable State health subsidy program'' 
     means--
       (1) the program under this title for the enrollment in 
     qualified health plans offered through an Exchange, including 
     the premium tax credits under section 36B of the Internal 
     Revenue Code of 1986 and cost-sharing reductions under 
     section 1402;
       (2) a State medicaid program under title XIX of the Social 
     Security Act;
       (3) a State children's health insurance program (CHIP) 
     under title XXI of such Act; and
       (4) a State program under section 1331 establishing 
     qualified basic health plans.

     SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS 
                   FOR CERTAIN PROGRAMS.

       (a) Disclosure of Taxpayer Return Information and Social 
     Security Numbers.--
       (1) Taxpayer return information.--Subsection (l) of section 
     6103 of the Internal Revenue Code of 1986 is amended by 
     adding at the end the following new paragraph:
       ``(21) Disclosure of return information to carry out 
     eligibility requirements for certain programs.--
       ``(A) In general.--The Secretary, upon written request from 
     the Secretary of Health and Human Services, shall disclose to 
     officers, employees, and contractors of the Department of 
     Health and Human Services return information of any taxpayer 
     whose income is relevant in determining any premium tax 
     credit under section 36B or any cost-sharing reduction under 
     section 1402 of the Patient Protection and Affordable Care 
     Act or eligibility for participation in a State medicaid 
     program under title XIX of the Social Security Act, a State's 
     children's health insurance program under title XXI of the 
     Social Security Act, or a basic health program under section 
     1331 of Patient Protection and Affordable Care Act. Such 
     return information shall be limited to--
       ``(i) taxpayer identity information with respect to such 
     taxpayer,
       ``(ii) the filing status of such taxpayer,
       ``(iii) the number of individuals for whom a deduction is 
     allowed under section 151 with respect to the taxpayer 
     (including the taxpayer and the taxpayer's spouse),
       ``(iv) the modified gross income (as defined in section 
     36B) of such taxpayer and each of the other individuals 
     included under clause (iii) who are required to file a return 
     of tax imposed by chapter 1 for the taxable year,
       ``(v) such other information as is prescribed by the 
     Secretary by regulation as might indicate whether the 
     taxpayer is eligible for such credit or reduction (and the 
     amount thereof), and
       ``(vi) the taxable year with respect to which the preceding 
     information relates or, if applicable, the fact that such 
     information is not available.
       ``(B) Information to exchange and state agencies.--The 
     Secretary of Health and Human Services may disclose to an 
     Exchange established under the Patient Protection and 
     Affordable Care Act or its contractors, or to a State agency 
     administering a State program described in subparagraph (A) 
     or its contractors, any inconsistency between the information 
     provided by the Exchange or State agency to the Secretary and 
     the information provided to the Secretary under subparagraph 
     (A).
       ``(C) Restriction on use of disclosed information.--Return 
     information disclosed under subparagraph (A) or (B) may be 
     used by officers, employees, and contractors of the 
     Department of Health and Human Services, an Exchange, or a 
     State agency only for the purposes of, and to the extent 
     necessary in--
       ``(i) establishing eligibility for participation in the 
     Exchange, and verifying the appropriate amount of, any credit 
     or reduction described in subparagraph (A),
       ``(ii) determining eligibility for participation in the 
     State programs described in subparagraph (A).''.
       (2) Social security numbers.--Section 205(c)(2)(C) of the 
     Social Security Act is amended by adding at the end the 
     following new clause:
       ``(x) The Secretary of Health and Human Services, and the 
     Exchanges established under section 1311 of the Patient 
     Protection and Affordable Care Act, are authorized to collect 
     and use the names and social security account numbers of 
     individuals as required to administer the provisions of, and 
     the amendments made by, the such Act.''.
       (b) Confidentiality and Disclosure.--Paragraph (3) of 
     section 6103(a) of such Code is amended by striking ``or 
     (20)'' and inserting ``(20), or (21)''.
       (c) Procedures and Recordkeeping Related to Disclosures.--
     Paragraph (4) of section 6103(p) of such Code is amended--
       (1) by inserting ``, or any entity described in subsection 
     (l)(21),'' after ``or (20)'' in the matter preceding 
     subparagraph (A),
       (2) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii), 
     and
       (3) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (20)'' both places it appears in the 
     matter after subparagraph (F).
       (d) Unauthorized Disclosure or Inspection.--Paragraph (2) 
     of section 7213(a) of such Code is amended by striking ``or 
     (20)'' and inserting ``(20), or (21)''.

     SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION 
                   PAYMENTS DISREGARDED FOR FEDERAL AND FEDERALLY-
                   ASSISTED PROGRAMS.

       For purposes of determining the eligibility of any 
     individual for benefits or assistance, or the amount or 
     extent of benefits or assistance, under any Federal program 
     or under any State or local program financed in whole or in 
     part with Federal funds--
       (1) any credit or refund allowed or made to any individual 
     by reason of section 36B of the Internal Revenue Code of 1986 
     (as added by section 1401) shall not be taken into account as 
     income and shall not be taken into account as resources for 
     the month of receipt and the following 2 months; and
       (2) any cost-sharing reduction payment or advance payment 
     of the credit allowed under such section 36B that is made 
     under section 1402 or 1412 shall be treated as made to the 
     qualified health plan in which an individual is enrolled and 
     not to that individual.

                   PART II--SMALL BUSINESS TAX CREDIT

     SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF 
                   SMALL BUSINESSES.

       (a) In General.--Subpart D of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     business-related credits) is amended by inserting after 
     section 45Q the following:

     ``SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL 
                   EMPLOYERS.

       ``(a) General Rule.--For purposes of section 38, in the 
     case of an eligible small employer, the small employer health 
     insurance credit determined under this section for any 
     taxable year in the credit period is the amount determined 
     under subsection (b).
       ``(b) Health Insurance Credit Amount.--Subject to 
     subsection (c), the amount determined under this subsection 
     with respect to any eligible small employer is equal to 50 
     percent (35 percent in the case of a tax-exempt eligible 
     small employer) of the lesser of--
       ``(1) the aggregate amount of nonelective contributions the 
     employer made on behalf of its employees during the taxable 
     year under the arrangement described in subsection (d)(4) for 
     premiums for qualified health plans offered by the employer 
     to its employees through an Exchange, or
       ``(2) the aggregate amount of nonelective contributions 
     which the employer would have made during the taxable year 
     under the arrangement if each employee taken into account 
     under paragraph (1) had enrolled in a qualified health plan 
     which had a premium equal to the average premium (as 
     determined by the Secretary of Health and Human Services) for 
     the small group market in the rating area in which the 
     employee enrolls for coverage.
       ``(c) Phaseout of Credit Amount Based on Number of 
     Employees and Average Wages.--The amount of the credit 
     determined under subsection (b) without regard to this 
     subsection shall be reduced (but not below zero) by the sum 
     of the following amounts:
       ``(1) Such amount multiplied by a fraction the numerator of 
     which is the total number of full-time equivalent employees 
     of the employer in excess of 10 and the denominator of which 
     is 15.
       ``(2) Such amount multiplied by a fraction the numerator of 
     which is the average annual wages of the employer in excess 
     of the dollar amount in effect under subsection (d)(3)(B) and 
     the denominator of which is such dollar amount.
       ``(d) Eligible Small Employer.--For purposes of this 
     section--
       ``(1) In general.--The term `eligible small employer' 
     means, with respect to any taxable year, an employer--
       ``(A) which has no more than 25 full-time equivalent 
     employees for the taxable year,
       ``(B) the average annual wages of which do not exceed an 
     amount equal to twice the dollar amount in effect under 
     paragraph (3)(B) for the taxable year, and
       ``(C) which has in effect an arrangement described in 
     paragraph (4).
       ``(2) Full-time equivalent employees.--
       ``(A) In general.--The term `full-time equivalent 
     employees' means a number of employees equal to the number 
     determined by dividing--
       ``(i) the total number of hours of service for which wages 
     were paid by the employer to employees during the taxable 
     year, by
       ``(ii) 2,080.

     Such number shall be rounded to the next lowest whole number 
     if not otherwise a whole number.
       ``(B) Excess hours not counted.--If an employee works in 
     excess of 2,080 hours of service during any taxable year, 
     such excess shall not be taken into account under 
     subparagraph (A).
       ``(C) Hours of service.--The Secretary, in consultation 
     with the Secretary of Labor, shall prescribe such 
     regulations, rules, and guidance as may be necessary to 
     determine the hours of service of an employee, including 
     rules for the application of this paragraph to employees who 
     are not compensated on an hourly basis.
       ``(3) Average annual wages.--
       ``(A) In general.--The average annual wages of an eligible 
     small employer for any taxable year is the amount determined 
     by dividing--
       ``(i) the aggregate amount of wages which were paid by the 
     employer to employees during the taxable year, by
       ``(ii) the number of full-time equivalent employees of the 
     employee determined under paragraph (2) for the taxable year.
     Such amount shall be rounded to the next lowest multiple of 
     $1,000 if not otherwise such a multiple.

[[Page 4236]]

       ``(B) Dollar amount.--For purposes of paragraph (1)(B)--
       ``(i) 2011, 2012, and 2013.--The dollar amount in effect 
     under this paragraph for taxable years beginning in 2011, 
     2012, or 2013 is $20,000.
       ``(ii) Subsequent years.--In the case of a taxable year 
     beginning in a calendar year after 2013, the dollar amount in 
     effect under this paragraph shall be equal to $20,000, 
     multiplied by the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2012' for `calendar year 1992' in 
     subparagraph (B) thereof.
       ``(4) Contribution arrangement.--An arrangement is 
     described in this paragraph if it requires an eligible small 
     employer to make a nonelective contribution on behalf of each 
     employee who enrolls in a qualified health plan offered to 
     employees by the employer through an exchange in an amount 
     equal to a uniform percentage (not less than 50 percent) of 
     the premium cost of the qualified health plan.
       ``(5) Seasonal worker hours and wages not counted.--For 
     purposes of this subsection--
       ``(A) In general.--The number of hours of service worked 
     by, and wages paid to, a seasonal worker of an employer shall 
     not be taken into account in determining the full-time 
     equivalent employees and average annual wages of the employer 
     unless the worker works for the employer on more than 120 
     days during the taxable year.
       ``(B) Definition of seasonal worker.--The term `seasonal 
     worker' means a worker who performs labor or services on a 
     seasonal basis as defined by the Secretary of Labor, 
     including workers covered by section 500.20(s)(1) of title 
     29, Code of Federal Regulations and retail workers employed 
     exclusively during holiday seasons.
       ``(e) Other Rules and Definitions.--For purposes of this 
     section--
       ``(1) Employee.--
       ``(A) Certain employees excluded.--The term `employee' 
     shall not include--
       ``(i) an employee within the meaning of section 401(c)(1),
       ``(ii) any 2-percent shareholder (as defined in section 
     1372(b)) of an eligible small business which is an S 
     corporation,
       ``(iii) any 5-percent owner (as defined in section 
     416(i)(1)(B)(i)) of an eligible small business, or
       ``(iv) any individual who bears any of the relationships 
     described in subparagraphs (A) through (G) of section 
     152(d)(2) to, or is a dependent described in section 
     152(d)(2)(H) of, an individual described in clause (i), (ii), 
     or (iii).
       ``(B) Leased employees.--The term `employee' shall include 
     a leased employee within the meaning of section 414(n).
       ``(2) Credit period.--The term `credit period' means, with 
     respect to any eligible small employer, the 2-consecutive-
     taxable year period beginning with the 1st taxable year in 
     which the employer (or any predecessor) offers 1 or more 
     qualified health plans to its employees through an Exchange.
       ``(3) Nonelective contribution.--The term `nonelective 
     contribution' means an employer contribution other than an 
     employer contribution pursuant to a salary reduction 
     arrangement.
       ``(4) Wages.--The term `wages' has the meaning given such 
     term by section 3121(a) (determined without regard to any 
     dollar limitation contained in such section).
       ``(5) Aggregation and other rules made applicable.--
       ``(A) Aggregation rules.--All employers treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414 shall be treated as a single employer for purposes of 
     this section.
       ``(B) Other rules.--Rules similar to the rules of 
     subsections (c), (d), and (e) of section 52 shall apply.
       ``(f) Credit Made Available to Tax-exempt Eligible Small 
     Employers.--
       ``(1) In general.--In the case of a tax-exempt eligible 
     small employer, there shall be treated as a credit allowable 
     under subpart C (and not allowable under this subpart) the 
     lesser of--
       ``(A) the amount of the credit determined under this 
     section with respect to such employer, or
       ``(B) the amount of the payroll taxes of the employer 
     during the calendar year in which the taxable year begins.
       ``(2) Tax-exempt eligible small employer.--For purposes of 
     this section, the term `tax-exempt eligible small employer' 
     means an eligible small employer which is any organization 
     described in section 501(c) which is exempt from taxation 
     under section 501(a).
       ``(3) Payroll taxes.--For purposes of this subsection--
       ``(A) In general.--The term `payroll taxes' means--
       ``(i) amounts required to be withheld from the employees of 
     the tax-exempt eligible small employer under section 3401(a),
       ``(ii) amounts required to be withheld from such employees 
     under section 3101(b), and
       ``(iii) amounts of the taxes imposed on the tax-exempt 
     eligible small employer under section 3111(b).
       ``(B) Special rule.--A rule similar to the rule of section 
     24(d)(2)(C) shall apply for purposes of subparagraph (A).
       ``(g) Application of Section for Calendar Years 2011, 2012, 
     and 2013.--In the case of any taxable year beginning in 2011, 
     2012, or 2013, the following modifications to this section 
     shall apply in determining the amount of the credit under 
     subsection (a):
       ``(1) No credit period required.--The credit shall be 
     determined without regard to whether the taxable year is in a 
     credit period and for purposes of applying this section to 
     taxable years beginning after 2013, no credit period shall be 
     treated as beginning with a taxable year beginning before 
     2014.
       ``(2) Amount of credit.--The amount of the credit 
     determined under subsection (b) shall be determined--
       ``(A) by substituting `35 percent (25 percent in the case 
     of a tax-exempt eligible small employer)' for `50 percent (35 
     percent in the case of a tax-exempt eligible small 
     employer)',
       ``(B) by reference to an eligible small employer's 
     nonelective contributions for premiums paid for health 
     insurance coverage (within the meaning of section 9832(b)(1)) 
     of an employee, and
       ``(C) by substituting for the average premium determined 
     under subsection (b)(2) the amount the Secretary of Health 
     and Human Services determines is the average premium for the 
     small group market in the State in which the employer is 
     offering health insurance coverage (or for such area within 
     the State as is specified by the Secretary).
       ``(3) Contribution arrangement.--An arrangement shall not 
     fail to meet the requirements of subsection (d)(4) solely 
     because it provides for the offering of insurance outside of 
     an Exchange.
       ``(h) Insurance Definitions.--Any term used in this section 
     which is also used in the Public Health Service Act or 
     subtitle A of title I of the Patient Protection and 
     Affordable Care Act shall have the meaning given such term by 
     such Act or subtitle.
       ``(i) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary to carry out the provisions 
     of this section, including regulations to prevent the 
     avoidance of the 2-year limit on the credit period through 
     the use of successor entities and the avoidance of the 
     limitations under subsection (c) through the use of multiple 
     entities.''.
       (b) Credit To Be Part of General Business Credit.--Section 
     38(b) of the Internal Revenue Code of 1986 (relating to 
     current year business credit) is amended by striking ``plus'' 
     at the end of paragraph (34), by striking the period at the 
     end of paragraph (35) and inserting ``, plus'', and by 
     inserting after paragraph (35) the following:
       ``(36) the small employer health insurance credit 
     determined under section 45R.''.
       (c) Credit Allowed Against Alternative Minimum Tax.--
     Section 38(c)(4)(B) of the Internal Revenue Code of 1986 
     (defining specified credits) is amended by redesignating 
     clauses (vi), (vii), and (viii) as clauses (vii), (viii), and 
     (ix), respectively, and by inserting after clause (v) the 
     following new clause:
       ``(vi) the credit determined under section 45R,''.
       (d) Disallowance of Deduction for Certain Expenses for 
     Which Credit Allowed.--
       (1) In general.--Section 280C of the Internal Revenue Code 
     of 1986 (relating to disallowance of deduction for certain 
     expenses for which credit allowed), as amended by section 
     1401(b), is amended by adding at the end the following new 
     subsection:
       ``(h) Credit for Employee Health Insurance Expenses of 
     Small Employers.--No deduction shall be allowed for that 
     portion of the premiums for qualified health plans (as 
     defined in section 1301(a) of the Patient Protection and 
     Affordable Care Act), or for health insurance coverage in the 
     case of taxable years beginning in 2011, 2012, or 2013, paid 
     by an employer which is equal to the amount of the credit 
     determined under section 45R(a) with respect to the 
     premiums.''.
       (2) Deduction for expiring credits.--Section 196(c) of such 
     Code is amended by striking ``and'' at the end of paragraph 
     (12), by striking the period at the end of paragraph (13) and 
     inserting ``, and'', and by adding at the end the following 
     new paragraph:
       ``(14) the small employer health insurance credit 
     determined under section 45R(a).''.
       (e) Clerical Amendment.--The table of sections for subpart 
     D of part IV of subchapter A of chapter 1 of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following:

``Sec. 45R. Employee health insurance expenses of small employers.''.

       (f) Effective Dates.--
       (1) In general.--The amendments made by this section shall 
     apply to amounts paid or incurred in taxable years beginning 
     after December 31, 2010.
       (2) Minimum tax.--The amendments made by subsection (c) 
     shall apply to credits determined under section 45R of the 
     Internal Revenue Code of 1986 in taxable years beginning 
     after December 31, 2010, and to carrybacks of such credits.

           Subtitle F--Shared Responsibility for Health Care

                   PART I--INDIVIDUAL RESPONSIBILITY

     SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL 
                   COVERAGE.

       (a) Findings.--Congress makes the following findings:
       (1) In general.--The individual responsibility requirement 
     provided for in this section (in this subsection referred to 
     as the ``requirement'') is commercial and economic in nature, 
     and substantially affects interstate commerce, as a result of 
     the effects described in paragraph (2).
       (2) Effects on the national economy and interstate 
     commerce.--The effects described in this paragraph are the 
     following:
       (A) The requirement regulates activity that is commercial 
     and economic in nature: economic and financial decisions 
     about how and when health care is paid for, and when health 
     insurance is purchased.

[[Page 4237]]

       (B) Health insurance and health care services are a 
     significant part of the national economy. National health 
     spending is projected to increase from $2,500,000,000,000, or 
     17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 
     2019. Private health insurance spending is projected to be 
     $854,000,000,000 in 2009, and pays for medical supplies, 
     drugs, and equipment that are shipped in interstate commerce. 
     Since most health insurance is sold by national or regional 
     health insurance companies, health insurance is sold in 
     interstate commerce and claims payments flow through 
     interstate commerce.
       (C) The requirement, together with the other provisions of 
     this Act, will add millions of new consumers to the health 
     insurance market, increasing the supply of, and demand for, 
     health care services. According to the Congressional Budget 
     Office, the requirement will increase the number and share of 
     Americans who are insured.
       (D) The requirement achieves near-universal coverage by 
     building upon and strengthening the private employer-based 
     health insurance system, which covers 176,000,000 Americans 
     nationwide. In Massachusetts, a similar requirement has 
     strengthened private employer-based coverage: despite the 
     economic downturn, the number of workers offered employer-
     based coverage has actually increased.
       (E) Half of all personal bankruptcies are caused in part by 
     medical expenses. By significantly increasing health 
     insurance coverage, the requirement, together with the other 
     provisions of this Act, will improve financial security for 
     families.
       (F) Under the Employee Retirement Income Security Act of 
     1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act 
     (42 U.S.C. 201 et seq.), and this Act, the Federal Government 
     has a significant role in regulating health insurance which 
     is in interstate commerce.
       (G) Under sections 2704 and 2705 of the Public Health 
     Service Act (as added by section 1201 of this Act), if there 
     were no requirement, many individuals would wait to purchase 
     health insurance until they needed care. By significantly 
     increasing health insurance coverage, the requirement, 
     together with the other provisions of this Act, will minimize 
     this adverse selection and broaden the health insurance risk 
     pool to include healthy individuals, which will lower health 
     insurance premiums. The requirement is essential to creating 
     effective health insurance markets in which improved health 
     insurance products that are guaranteed issue and do not 
     exclude coverage of pre-existing conditions can be sold.
       (H) Administrative costs for private health insurance, 
     which were $90,000,000,000 in 2006, are 26 to 30 percent of 
     premiums in the current individual and small group markets. 
     By significantly increasing health insurance coverage and the 
     size of purchasing pools, which will increase economies of 
     scale, the requirement, together with the other provisions of 
     this Act, will significantly reduce administrative costs and 
     lower health insurance premiums. The requirement is essential 
     to creating effective health insurance markets that do not 
     require underwriting and eliminate its associated 
     administrative costs.
       (3) Supreme court ruling.--In United States v. South-
     Eastern Underwriters Association (322 U.S. 533 (1944)), the 
     Supreme Court of the United States ruled that insurance is 
     interstate commerce subject to Federal regulation.
       (b) In General.--Subtitle D of the Internal Revenue Code of 
     1986 is amended by adding at the end the following new 
     chapter:

        ``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE

``Sec. 5000A. Requirement to maintain minimum essential coverage.

     ``SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL 
                   COVERAGE.

       ``(a) Requirement To Maintain Minimum Essential Coverage.--
     An applicable individual shall for each month beginning after 
     2013 ensure that the individual, and any dependent of the 
     individual who is an applicable individual, is covered under 
     minimum essential coverage for such month.
       ``(b) Shared Responsibility Payment.--
       ``(1) In general.--If an applicable individual fails to 
     meet the requirement of subsection (a) for 1 or more months 
     during any calendar year beginning after 2013, then, except 
     as provided in subsection (d), there is hereby imposed a 
     penalty with respect to the individual in the amount 
     determined under subsection (c).
       ``(2) Inclusion with return.--Any penalty imposed by this 
     section with respect to any month shall be included with a 
     taxpayer's return under chapter 1 for the taxable year which 
     includes such month.
       ``(3) Payment of penalty.--If an individual with respect to 
     whom a penalty is imposed by this section for any month--
       ``(A) is a dependent (as defined in section 152) of another 
     taxpayer for the other taxpayer's taxable year including such 
     month, such other taxpayer shall be liable for such penalty, 
     or
       ``(B) files a joint return for the taxable year including 
     such month, such individual and the spouse of such individual 
     shall be jointly liable for such penalty.
       ``(c) Amount of Penalty.--
       ``(1) In general.--The penalty determined under this 
     subsection for any month with respect to any individual is an 
     amount equal to \1/12\ of the applicable dollar amount for 
     the calendar year.
       ``(2) Dollar limitation.--The amount of the penalty imposed 
     by this section on any taxpayer for any taxable year with 
     respect to all individuals for whom the taxpayer is liable 
     under subsection (b)(3) shall not exceed an amount equal to 
     300 percent the applicable dollar amount (determined without 
     regard to paragraph (3)(C)) for the calendar year with or 
     within which the taxable year ends.
       ``(3) Applicable dollar amount.--For purposes of paragraph 
     (1)--
       ``(A) In general.--Except as provided in subparagraphs (B) 
     and (C), the applicable dollar amount is $750.
       ``(B) Phase in.--The applicable dollar amount is $95 for 
     2014 and $350 for 2015.
       ``(C) Special rule for individuals under age 18.--If an 
     applicable individual has not attained the age of 18 as of 
     the beginning of a month, the applicable dollar amount with 
     respect to such individual for the month shall be equal to 
     one-half of the applicable dollar amount for the calendar 
     year in which the month occurs.
       ``(D) Indexing of amount.--In the case of any calendar year 
     beginning after 2016, the applicable dollar amount shall be 
     equal to $750, increased by an amount equal to--
       ``(i) $750, multiplied by
       ``(ii) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2015' for `calendar year 1992' in 
     subparagraph (B) thereof.

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       ``(4) Terms relating to income and families.--For purposes 
     of this section--
       ``(A) Family size.--The family size involved with respect 
     to any taxpayer shall be equal to the number of individuals 
     for whom the taxpayer is allowed a deduction under section 
     151 (relating to allowance of deduction for personal 
     exemptions) for the taxable year.
       ``(B) Household income.--The term `household income' means, 
     with respect to any taxpayer for any taxable year, an amount 
     equal to the sum of--
       ``(i) the modified gross income of the taxpayer, plus
       ``(ii) the aggregate modified gross incomes of all other 
     individuals who--

       ``(I) were taken into account in determining the taxpayer's 
     family size under paragraph (1), and
       ``(II) were required to file a return of tax imposed by 
     section 1 for the taxable year.

       ``(C) Modified gross income.--The term `modified gross 
     income' means gross income--
       ``(i) decreased by the amount of any deduction allowable 
     under paragraph (1), (3), (4), or (10) of section 62(a),
       ``(ii) increased by the amount of interest received or 
     accrued during the taxable year which is exempt from tax 
     imposed by this chapter, and
       ``(iii) determined without regard to sections 911, 931, and 
     933.
       ``(D) Poverty line.--
       ``(i) In general.--The term `poverty line' has the meaning 
     given that term in section 2110(c)(5) of the Social Security 
     Act (42 U.S.C. 1397jj(c)(5)).
       ``(ii) Poverty line used.--In the case of any taxable year 
     ending with or within a calendar year, the poverty line used 
     shall be the most recently published poverty line as of the 
     1st day of such calendar year.
       ``(d) Applicable Individual.--For purposes of this 
     section--
       ``(1) In general.--The term `applicable individual' means, 
     with respect to any month, an individual other than an 
     individual described in paragraph (2), (3), or (4).
       ``(2) Religious exemptions.--
       ``(A) Religious conscience exemption.--Such term shall not 
     include any individual for any month if such individual has 
     in effect an exemption under section 1311(d)(4)(H) of the 
     Patient Protection and Affordable Care Act which certifies 
     that such individual is a member of a recognized religious 
     sect or division thereof described in section 1402(g)(1) and 
     an adherent of established tenets or teachings of such sect 
     or division as described in such section.
       ``(B) Health care sharing ministry.--
       ``(i) In general.--Such term shall not include any 
     individual for any month if such individual is a member of a 
     health care sharing ministry for the month.
       ``(ii) Health care sharing ministry.--The term `health care 
     sharing ministry' means an organization--

       ``(I) which is described in section 501(c)(3) and is exempt 
     from taxation under section 501(a),
       ``(II) members of which share a common set of ethical or 
     religious beliefs and share medical expenses among members in 
     accordance with those beliefs and without regard to the State 
     in which a member resides or is employed,
       ``(III) members of which retain membership even after they 
     develop a medical condition,
       ``(IV) which (or a predecessor of which) has been in 
     existence at all times since December 31, 1999, and medical 
     expenses of its members have been shared continuously and 
     without interruption since at least December 31, 1999, and
       ``(V) which conducts an annual audit which is performed by 
     an independent certified public accounting firm in accordance 
     with generally accepted accounting principles and which is 
     made available to the public upon request.

       ``(3) Individuals not lawfully present.--Such term shall 
     not include an individual for any month if for the month the 
     individual is not a citizen or national of the United States 
     or an alien lawfully present in the United States.
       ``(4) Incarcerated individuals.--Such term shall not 
     include an individual for any month if

[[Page 4238]]

     for the month the individual is incarcerated, other than 
     incarceration pending the disposition of charges.
       ``(e) Exemptions.--No penalty shall be imposed under 
     subsection (a) with respect to--
       ``(1) Individuals who cannot afford coverage.--
       ``(A) In general.--Any applicable individual for any month 
     if the applicable individual's required contribution 
     (determined on an annual basis) for coverage for the month 
     exceeds 8 percent of such individual's household income for 
     the taxable year described in section 1412(b)(1)(B) of the 
     Patient Protection and Affordable Care Act. For purposes of 
     applying this subparagraph, the taxpayer's household income 
     shall be increased by any exclusion from gross income for any 
     portion of the required contribution made through a salary 
     reduction arrangement.
       ``(B) Required contribution.--For purposes of this 
     paragraph, the term `required contribution' means--
       ``(i) in the case of an individual eligible to purchase 
     minimum essential coverage consisting of coverage through an 
     eligible-employer-sponsored plan, the portion of the annual 
     premium which would be paid by the individual (without regard 
     to whether paid through salary reduction or otherwise) for 
     self-only coverage, or
       ``(ii) in the case of an individual eligible only to 
     purchase minimum essential coverage described in subsection 
     (f)(1)(C), the annual premium for the lowest cost bronze plan 
     available in the individual market through the Exchange in 
     the State in the rating area in which the individual resides 
     (without regard to whether the individual purchased a 
     qualified health plan through the Exchange), reduced by the 
     amount of the credit allowable under section 36B for the 
     taxable year (determined as if the individual was covered by 
     a qualified health plan offered through the Exchange for the 
     entire taxable year).
       ``(C) Special rules for individuals related to employees.--
     For purposes of subparagraph (B)(i), if an applicable 
     individual is eligible for minimum essential coverage through 
     an employer by reason of a relationship to an employee, the 
     determination shall be made by reference to the affordability 
     of the coverage to the employee.
       ``(D) Indexing.--In the case of plan years beginning in any 
     calendar year after 2014, subparagraph (A) shall be applied 
     by substituting for `8 percent' the percentage the Secretary 
     of Health and Human Services determines reflects the excess 
     of the rate of premium growth between the preceding calendar 
     year and 2013 over the rate of income growth for such period.
       ``(2) Taxpayers with income under 100 percent of poverty 
     line.--Any applicable individual for any month during a 
     calendar year if the individual's household income for the 
     taxable year described in section 1412(b)(1)(B) of the 
     Patient Protection and Affordable Care Act is less than 100 
     percent of the poverty line for the size of the family 
     involved (determined in the same manner as under subsection 
     (b)(4)).
       ``(3) Members of indian tribes.--Any applicable individual 
     for any month during which the individual is a member of an 
     Indian tribe (as defined in section 45A(c)(6)).
       ``(4) Months during short coverage gaps.--
       ``(A) In general.--Any month the last day of which occurred 
     during a period in which the applicable individual was not 
     covered by minimum essential coverage for a continuous period 
     of less than 3 months.
       ``(B) Special rules.--For purposes of applying this 
     paragraph--
       ``(i) the length of a continuous period shall be determined 
     without regard to the calendar years in which months in such 
     period occur,
       ``(ii) if a continuous period is greater than the period 
     allowed under subparagraph (A), no exception shall be 
     provided under this paragraph for any month in the period, 
     and
       ``(iii) if there is more than 1 continuous period described 
     in subparagraph (A) covering months in a calendar year, the 
     exception provided by this paragraph shall only apply to 
     months in the first of such periods.

     The Secretary shall prescribe rules for the collection of the 
     penalty imposed by this section in cases where continuous 
     periods include months in more than 1 taxable year.
       ``(5) Hardships.--Any applicable individual who for any 
     month is determined by the Secretary of Health and Human 
     Services under section 1311(d)(4)(H) to have suffered a 
     hardship with respect to the capability to obtain coverage 
     under a qualified health plan.
       ``(f) Minimum Essential Coverage.--For purposes of this 
     section--
       ``(1) In general.--The term `minimum essential coverage' 
     means any of the following:
       ``(A) Government sponsored programs.--Coverage under--
       ``(i) the Medicare program under part A of title XVIII of 
     the Social Security Act,
       ``(ii) the Medicaid program under title XIX of the Social 
     Security Act,
       ``(iii) the CHIP program under title XXI of the Social 
     Security Act,
       ``(iv) the TRICARE for Life program,
       ``(v) the veteran's health care program under chapter 17 of 
     title 38, United States Code, or
       ``(vi) a health plan under section 2504(e) of title 22, 
     United States Code (relating to Peace Corps volunteers).
       ``(B) Employer-sponsored plan.--Coverage under an eligible 
     employer-sponsored plan.
       ``(C) Plans in the individual market.--Coverage under a 
     health plan offered in the individual market within a State.
       ``(D) Grandfathered health plan.--Coverage under a 
     grandfathered health plan.
       ``(E) Other coverage.--Such other health benefits coverage, 
     such as a State health benefits risk pool, as the Secretary 
     of Health and Human Services, in coordination with the 
     Secretary, recognizes for purposes of this subsection.
       ``(2) Eligible employer-sponsored plan.--The term `eligible 
     employer-sponsored plan' means, with respect to any employee, 
     a group health plan or group health insurance coverage 
     offered by an employer to the employee which is--
       ``(A) a governmental plan (within the meaning of section 
     2791(d)(8) of the Public Health Service Act), or
       ``(B) any other plan or coverage offered in the small or 
     large group market within a State.
     Such term shall include a grandfathered health plan described 
     in paragraph (1)(D) offered in a group market.
       ``(3) Excepted benefits not treated as minimum essential 
     coverage.--The term `minimum essential coverage' shall not 
     include health insurance coverage which consists of coverage 
     of excepted benefits--
       ``(A) described in paragraph (1) of subsection (c) of 
     section 2791 of the Public Health Service Act; or
       ``(B) described in paragraph (2), (3), or (4) of such 
     subsection if the benefits are provided under a separate 
     policy, certificate, or contract of insurance.
       ``(4) Individuals residing outside united states or 
     residents of territories.--Any applicable individual shall be 
     treated as having minimum essential coverage for any month--
       ``(A) if such month occurs during any period described in 
     subparagraph (A) or (B) of section 911(d)(1) which is 
     applicable to the individual, or
       ``(B) if such individual is a bona fide resident of any 
     possession of the United States (as determined under section 
     937(a)) for such month.
       ``(5) Insurance-related terms.--Any term used in this 
     section which is also used in title I of the Patient 
     Protection and Affordable Care Act shall have the same 
     meaning as when used in such title.
       ``(g) Administration and Procedure.--
       ``(1) In general.--The penalty provided by this section 
     shall be paid upon notice and demand by the Secretary, and 
     except as provided in paragraph (2), shall be assessed and 
     collected in the same manner as an assessable penalty under 
     subchapter B of chapter 68.
       ``(2) Special rules.--Notwithstanding any other provision 
     of law--
       ``(A) Waiver of criminal penalties.--In the case of any 
     failure by a taxpayer to timely pay any penalty imposed by 
     this section, such taxpayer shall not be subject to any 
     criminal prosecution or penalty with respect to such failure.
       ``(B) Limitations on liens and levies.--The Secretary shall 
     not--
       ``(i) file notice of lien with respect to any property of a 
     taxpayer by reason of any failure to pay the penalty imposed 
     by this section, or
       ``(ii) levy on any such property with respect to such 
     failure.''.
       (c) Clerical Amendment.--The table of chapters for subtitle 
     D of the Internal Revenue Code of 1986 is amended by 
     inserting after the item relating to chapter 47 the following 
     new item:

      ``Chapter 48--Maintenance of Minimum Essential Coverage.''.

       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after December 31, 2013.

     SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.

       (a) In General.--Part III of subchapter A of chapter 61 of 
     the Internal Revenue Code of 1986 is amended by inserting 
     after subpart C the following new subpart:

      ``Subpart D--Information Regarding Health Insurance Coverage

``Sec. 6055. Reporting of health insurance coverage.

     ``SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.

       ``(a) In General.--Every person who provides minimum 
     essential coverage to an individual during a calendar year 
     shall, at such time as the Secretary may prescribe, make a 
     return described in subsection (b).
       ``(b) Form and Manner of Return.--
       ``(1) In general.--A return is described in this subsection 
     if such return--
       ``(A) is in such form as the Secretary may prescribe, and
       ``(B) contains--
       ``(i) the name, address and TIN of the primary insured and 
     the name and TIN of each other individual obtaining coverage 
     under the policy,
       ``(ii) the dates during which such individual was covered 
     under minimum essential coverage during the calendar year,
       ``(iii) in the case of minimum essential coverage which 
     consists of health insurance coverage, information 
     concerning--

       ``(I) whether or not the coverage is a qualified health 
     plan offered through an Exchange established under section 
     1311 of the Patient Protection and Affordable Care Act, and
       ``(II) in the case of a qualified health plan, the amount 
     (if any) of any advance payment under section 1412 of the 
     Patient Protection and Affordable Care Act of any cost-
     sharing reduction under section 1402 of such Act or of any 
     premium tax credit under section 36B with respect to such 
     coverage, and

       ``(iv) such other information as the Secretary may require.

[[Page 4239]]

       ``(2) Information relating to employer-provided coverage.--
     If minimum essential coverage provided to an individual under 
     subsection (a) consists of health insurance coverage of a 
     health insurance issuer provided through a group health plan 
     of an employer, a return described in this subsection shall 
     include--
       ``(A) the name, address, and employer identification number 
     of the employer maintaining the plan,
       ``(B) the portion of the premium (if any) required to be 
     paid by the employer, and
       ``(C) if the health insurance coverage is a qualified 
     health plan in the small group market offered through an 
     Exchange, such other information as the Secretary may require 
     for administration of the credit under section 45R (relating 
     to credit for employee health insurance expenses of small 
     employers).
       ``(c) Statements To Be Furnished to Individuals With 
     Respect to Whom Information Is Reported.--
       ``(1) In general.--Every person required to make a return 
     under subsection (a) shall furnish to each individual whose 
     name is required to be set forth in such return a written 
     statement showing--
       ``(A) the name and address of the person required to make 
     such return and the phone number of the information contact 
     for such person, and
       ``(B) the information required to be shown on the return 
     with respect to such individual.
       ``(2) Time for furnishing statements.--The written 
     statement required under paragraph (1) shall be furnished on 
     or before January 31 of the year following the calendar year 
     for which the return under subsection (a) was required to be 
     made.
       ``(d) Coverage Provided by Governmental Units.--In the case 
     of coverage provided by any governmental unit or any agency 
     or instrumentality thereof, the officer or employee who 
     enters into the agreement to provide such coverage (or the 
     person appropriately designated for purposes of this section) 
     shall make the returns and statements required by this 
     section.
       ``(e) Minimum Essential Coverage.--For purposes of this 
     section, the term `minimum essential coverage' has the 
     meaning given such term by section 5000A(f).''.
       (b) Assessable Penalties.--
       (1) Subparagraph (B) of section 6724(d)(1) of the Internal 
     Revenue Code of 1986 (relating to definitions) is amended by 
     striking ``or'' at the end of clause (xxii), by striking 
     ``and'' at the end of clause (xxiii) and inserting ``or'', 
     and by inserting after clause (xxiii) the following new 
     clause:
       ``(xxiv) section 6055 (relating to returns relating to 
     information regarding health insurance coverage), and''.
       (2) Paragraph (2) of section 6724(d) of such Code is 
     amended by striking ``or'' at the end of subparagraph (EE), 
     by striking the period at the end of subparagraph (FF) and 
     inserting ``, or'' and by inserting after subparagraph (FF) 
     the following new subparagraph:
       ``(GG) section 6055(c) (relating to statements relating to 
     information regarding health insurance coverage).''.
       (c) Notification of Nonenrollment.--Not later than June 30 
     of each year, the Secretary of the Treasury, acting through 
     the Internal Revenue Service and in consultation with the 
     Secretary of Health and Human Services, shall send a 
     notification to each individual who files an individual 
     income tax return and who is not enrolled in minimum 
     essential coverage (as defined in section 5000A of the 
     Internal Revenue Code of 1986). Such notification shall 
     contain information on the services available through the 
     Exchange operating in the State in which such individual 
     resides.
       (d) Conforming Amendment.--The table of subparts for part 
     III of subchapter A of chapter 61 of such Code is amended by 
     inserting after the item relating to subpart C the following 
     new item:

    ``subpart d--information regarding health insurance coverage''.

       (e) Effective Date.--The amendments made by this section 
     shall apply to calendar years beginning after 2013.

                   PART II--EMPLOYER RESPONSIBILITIES

     SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
                   EMPLOYERS.

       The Fair Labor Standards Act of 1938 is amended by 
     inserting after section 18 (29 U.S.C. 218) the following:

     ``SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
                   EMPLOYERS.

       ``In accordance with regulations promulgated by the 
     Secretary, an employer to which this Act applies that has 
     more than 200 full-time employees and that offers employees 
     enrollment in 1 or more health benefits plans shall 
     automatically enroll new full-time employees in one of the 
     plans offered (subject to any waiting period authorized by 
     law) and to continue the enrollment of current employees in a 
     health benefits plan offered through the employer. Any 
     automatic enrollment program shall include adequate notice 
     and the opportunity for an employee to opt out of any 
     coverage the individual or employee were automatically 
     enrolled in. Nothing in this section shall be construed to 
     supersede any State law which establishes, implements, or 
     continues in effect any standard or requirement relating to 
     employers in connection with payroll except to the extent 
     that such standard or requirement prevents an employer from 
     instituting the automatic enrollment program under this 
     section.''.

     SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF 
                   COVERAGE OPTIONS.

       The Fair Labor Standards Act of 1938 is amended by 
     inserting after section 18A (as added by section 1513) the 
     following:

     ``SEC. 18B. NOTICE TO EMPLOYEES.

       ``(a) In General.--In accordance with regulations 
     promulgated by the Secretary, an employer to which this Act 
     applies, shall provide to each employee at the time of hiring 
     (or with respect to current employees, not later than March 
     1, 2013), written notice--
       ``(1) informing the employee of the existence of an 
     Exchange, including a description of the services provided by 
     such Exchange, and the manner in which the employee may 
     contact the Exchange to request assistance;
       ``(2) if the employer plan's share of the total allowed 
     costs of benefits provided under the plan is less than 60 
     percent of such costs, that the employee may be eligible for 
     a premium tax credit under section 36B of the Internal 
     Revenue Code of 1986 and a cost sharing reduction under 
     section 1402 of the Patient Protection and Affordable Care 
     Act if the employee purchases a qualified health plan through 
     the Exchange; and
       ``(3) if the employee purchases a qualified health plan 
     through the Exchange, the employee will lose the employer 
     contribution (if any) to any health benefits plan offered by 
     the employer and that all or a portion of such contribution 
     may be excludable from income for Federal income tax 
     purposes.
       ``(b) Effective Date.--Subsection (a) shall take effect 
     with respect to employers in a State beginning on March 1, 
     2013.''.

     SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.

       (a) In General.--Chapter 43 of the Internal Revenue Code of 
     1986 is amended by adding at the end the following:

     ``SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING 
                   HEALTH COVERAGE.

       ``(a) Large Employers Not Offering Health Coverage.--If--
       ``(1) any applicable large employer fails to offer to its 
     full-time employees (and their dependents) the opportunity to 
     enroll in minimum essential coverage under an eligible 
     employer-sponsored plan (as defined in section 5000A(f)(2)) 
     for any month, and
       ``(2) at least one full-time employee of the applicable 
     large employer has been certified to the employer under 
     section 1411 of the Patient Protection and Affordable Care 
     Act as having enrolled for such month in a qualified health 
     plan with respect to which an applicable premium tax credit 
     or cost-sharing reduction is allowed or paid with respect to 
     the employee,

     then there is hereby imposed on the employer an assessable 
     payment equal to the product of the applicable payment amount 
     and the number of individuals employed by the employer as 
     full-time employees during such month.
       ``(b) Large Employers With Waiting Periods Exceeding 30 
     Days.--
       ``(1) In general.--In the case of any applicable large 
     employer which requires an extended waiting period to enroll 
     in any minimum essential coverage under an employer-sponsored 
     plan (as defined in section 5000A(f)(2)), there is hereby 
     imposed on the employer an assessable payment, in the amount 
     specified in paragraph (2), for each full-time employee of 
     the employer to whom the extended waiting period applies.
       ``(2) Amount.--For purposes of paragraph (1), the amount 
     specified in this paragraph for a full-time employee is--
       ``(A) in the case of an extended waiting period which 
     exceeds 30 days but does not exceed 60 days, $400, and
       ``(B) in the case of an extended waiting period which 
     exceeds 60 days, $600.
       ``(3) Extended waiting period.--The term `extended waiting 
     period' means any waiting period (as defined in section 
     2701(b)(4) of the Public Health Service Act) which exceeds 30 
     days.
       ``(c) Large Employers Offering Coverage With Employees Who 
     Qualify for Premium Tax Credits or Cost-sharing Reductions.--
       ``(1) In general.--If--
       ``(A) an applicable large employer offers to its full-time 
     employees (and their dependents) the opportunity to enroll in 
     minimum essential coverage under an eligible employer-
     sponsored plan (as defined in section 5000A(f)(2)) for any 
     month, and
       ``(B) 1 or more full-time employees of the applicable large 
     employer has been certified to the employer under section 
     1411 of the Patient Protection and Affordable Care Act as 
     having enrolled for such month in a qualified health plan 
     with respect to which an applicable premium tax credit or 
     cost-sharing reduction is allowed or paid with respect to the 
     employee,
     then there is hereby imposed on the employer an assessable 
     payment equal to the product of the number of full-time 
     employees of the applicable large employer described in 
     subparagraph (B) for such month and 400 percent of the 
     applicable payment amount.
       ``(2) Overall limitation.--The aggregate amount of tax 
     determined under paragraph (1) with respect to all employees 
     of an applicable large employer for any month shall not 
     exceed the product of the applicable payment amount and the 
     number of individuals employed by the employer as full-time 
     employees during such month.
       ``(d) Definitions and Special Rules.--For purposes of this 
     section--
       ``(1) Applicable payment amount.--The term `applicable 
     payment amount' means, with respect to any month, \1/12\ of 
     $750.

[[Page 4240]]

       ``(2) Applicable large employer.--
       ``(A) In general.--The term `applicable large employer' 
     means, with respect to a calendar year, an employer who 
     employed an average of at least 50 full-time employees on 
     business days during the preceding calendar year.
       ``(B) Exemption for certain employers.--
       ``(i) In general.--An employer shall not be considered to 
     employ more than 50 full-time employees if--

       ``(I) the employer's workforce exceeds 50 full-time 
     employees for 120 days or fewer during the calendar year, and
       ``(II) the employees in excess of 50 employed during such 
     120-day period were seasonal workers.

       ``(ii) Definition of seasonal workers.--The term `seasonal 
     worker' means a worker who performs labor or services on a 
     seasonal basis as defined by the Secretary of Labor, 
     including workers covered by section 500.20(s)(1) of title 
     29, Code of Federal Regulations and retail workers employed 
     exclusively during holiday seasons.
       ``(C) Rules for determining employer size.--For purposes of 
     this paragraph--
       ``(i) Application of aggregation rule for employers.--All 
     persons treated as a single employer under subsection (b), 
     (c), (m), or (o) of section 414 of the Internal Revenue Code 
     of 1986 shall be treated as 1 employer.
       ``(ii) Employers not in existence in preceding year.--In 
     the case of an employer which was not in existence throughout 
     the preceding calendar year, the determination of whether 
     such employer is an applicable large employer shall be based 
     on the average number of employees that it is reasonably 
     expected such employer will employ on business days in the 
     current calendar year.
       ``(iii) Predecessors.--Any reference in this subsection to 
     an employer shall include a reference to any predecessor of 
     such employer.
       ``(3) Applicable premium tax credit and cost-sharing 
     reduction.--The term `applicable premium tax credit and cost-
     sharing reduction' means--
       ``(A) any premium tax credit allowed under section 36B,
       ``(B) any cost-sharing reduction under section 1402 of the 
     Patient Protection and Affordable Care Act, and
       ``(C) any advance payment of such credit or reduction under 
     section 1412 of such Act.
       ``(4) Full-time employee.--
       ``(A) In general.--The term `full-time employee' means an 
     employee who is employed on average at least 30 hours of 
     service per week.
       ``(B) Hours of service.--The Secretary, in consultation 
     with the Secretary of Labor, shall prescribe such 
     regulations, rules, and guidance as may be necessary to 
     determine the hours of service of an employee, including 
     rules for the application of this paragraph to employees who 
     are not compensated on an hourly basis.
       ``(5) Inflation adjustment.--
       ``(A) In general.--In the case of any calendar year after 
     2014, each of the dollar amounts in subsection (b)(2) and 
     (d)(1) shall be increased by an amount equal to the product 
     of--
       ``(i) such dollar amount, and
       ``(ii) the premium adjustment percentage (as defined in 
     section 1302(c)(4) of the Patient Protection and Affordable 
     Care Act) for the calendar year.
       ``(B) Rounding.--If the amount of any increase under 
     subparagraph (A) is not a multiple of $10, such increase 
     shall be rounded to the next lowest multiple of $10.
       ``(6) Other definitions.--Any term used in this section 
     which is also used in the Patient Protection and Affordable 
     Care Act shall have the same meaning as when used in such 
     Act.
       ``(7) Tax nondeductible.--For denial of deduction for the 
     tax imposed by this section, see section 275(a)(6).
       ``(e) Administration and Procedure.--
       ``(1) In general.--Any assessable payment provided by this 
     section shall be paid upon notice and demand by the 
     Secretary, and shall be assessed and collected in the same 
     manner as an assessable penalty under subchapter B of chapter 
     68.
       ``(2) Time for payment.--The Secretary may provide for the 
     payment of any assessable payment provided by this section on 
     an annual, monthly, or other periodic basis as the Secretary 
     may prescribe.
       ``(3) Coordination with credits, etc..--The Secretary shall 
     prescribe rules, regulations, or guidance for the repayment 
     of any assessable payment (including interest) if such 
     payment is based on the allowance or payment of an applicable 
     premium tax credit or cost-sharing reduction with respect to 
     an employee, such allowance or payment is subsequently 
     disallowed, and the assessable payment would not have been 
     required to be made but for such allowance or payment.''.
       (b) Clerical Amendment.--The table of sections for chapter 
     43 of such Code is amended by adding at the end the following 
     new item:

``Sec. 4980H. Shared responsibility for employers regarding health 
              coverage.''.

       (c) Study and Report of Effect of Tax on Workers' Wages.--
       (1) In general.--The Secretary of Labor shall conduct a 
     study to determine whether employees' wages are reduced by 
     reason of the application of the assessable payments under 
     section 4980H of the Internal Revenue Code of 1986 (as added 
     by the amendments made by this section). The Secretary shall 
     make such determination on the basis of the National 
     Compensation Survey published by the Bureau of Labor 
     Statistics.
       (2) Report.--The Secretary shall report the results of the 
     study under paragraph (1) to the Committee on Ways and Means 
     of the House of Representatives and to the Committee on 
     Finance of the Senate.
       (d) Effective Date.--The amendments made by this section 
     shall apply to months beginning after December 31, 2013.

     SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE.

       (a) In General.--Subpart D of part III of subchapter A of 
     chapter 61 of the Internal Revenue Code of 1986, as added by 
     section 1502, is amended by inserting after section 6055 the 
     following new section:

     ``SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH 
                   INSURANCE COVERAGE.

       ``(a) In General.--Every applicable large employer required 
     to meet the requirements of section 4980H with respect to its 
     full-time employees during a calendar year shall, at such 
     time as the Secretary may prescribe, make a return described 
     in subsection (b).
       ``(b) Form and Manner of Return.--A return is described in 
     this subsection if such return--
       ``(1) is in such form as the Secretary may prescribe, and
       ``(2) contains--
       ``(A) the name, date, and employer identification number of 
     the employer,
       ``(B) a certification as to whether the employer offers to 
     its full-time employees (and their dependents) the 
     opportunity to enroll in minimum essential coverage under an 
     eligible employer-sponsored plan (as defined in section 
     5000A(f)(2)),
       ``(C) if the employer certifies that the employer did offer 
     to its full-time employees (and their dependents) the 
     opportunity to so enroll--
       ``(i) the length of any waiting period (as defined in 
     section 2701(b)(4) of the Public Health Service Act) with 
     respect to such coverage,
       ``(ii) the months during the calendar year for which 
     coverage under the plan was available,
       ``(iii) the monthly premium for the lowest cost option in 
     each of the enrollment categories under the plan, and
       ``(iv) the applicable large employer's share of the total 
     allowed costs of benefits provided under the plan,
       ``(D) the number of full-time employees for each month 
     during the calendar year,
       ``(E) the name, address, and TIN of each full-time employee 
     during the calendar year and the months (if any) during which 
     such employee (and any dependents) were covered under any 
     such health benefits plans, and
       ``(F) such other information as the Secretary may require.
       ``(c) Statements To Be Furnished to Individuals With 
     Respect to Whom Information Is Reported.--
       ``(1) In general.--Every person required to make a return 
     under subsection (a) shall furnish to each full-time employee 
     whose name is required to be set forth in such return under 
     subsection (b)(2)(E) a written statement showing--
       ``(A) the name and address of the person required to make 
     such return and the phone number of the information contact 
     for such person, and
       ``(B) the information required to be shown on the return 
     with respect to such individual.
       ``(2) Time for furnishing statements.--The written 
     statement required under paragraph (1) shall be furnished on 
     or before January 31 of the year following the calendar year 
     for which the return under subsection (a) was required to be 
     made.
       ``(d) Coordination With Other Requirements.--To the maximum 
     extent feasible, the Secretary may provide that--
       ``(1) any return or statement required to be provided under 
     this section may be provided as part of any return or 
     statement required under section 6051 or 6055, and
       ``(2) in the case of an applicable large employer offering 
     health insurance coverage of a health insurance issuer, the 
     employer may enter into an agreement with the issuer to 
     include information required under this section with the 
     return and statement required to be provided by the issuer 
     under section 6055.
       ``(e) Coverage Provided by Governmental Units.--In the case 
     of any applicable large employer which is a governmental unit 
     or any agency or instrumentality thereof, the person 
     appropriately designated for purposes of this section shall 
     make the returns and statements required by this section.
       ``(f) Definitions.--For purposes of this section, any term 
     used in this section which is also used in section 4980H 
     shall have the meaning given such term by section 4980H.''.
       (b) Assessable Penalties.--
       (1) Subparagraph (B) of section 6724(d)(1) of the Internal 
     Revenue Code of 1986 (relating to definitions), as amended by 
     section 1502, is amended by striking ``or'' at the end of 
     clause (xxiii), by striking ``and'' at the end of clause 
     (xxiv) and inserting ``or'', and by inserting after clause 
     (xxiv) the following new clause:
       ``(xxv) section 6056 (relating to returns relating to large 
     employers required to report on health insurance coverage), 
     and''.
       (2) Paragraph (2) of section 6724(d) of such Code, as so 
     amended, is amended by striking ``or'' at the end of 
     subparagraph (FF), by striking the period at the end of 
     subparagraph (GG) and inserting ``, or'' and by inserting 
     after subparagraph (GG) the following new subparagraph:
       ``(HH) section 6056(c) (relating to statements relating to 
     large employers required to report on health insurance 
     coverage).''.
       (c) Conforming Amendment.--The table of sections for 
     subpart D of part III of subchapter

[[Page 4241]]

     A of chapter 61 of such Code, as added by section 1502, is 
     amended by adding at the end the following new item:

``Sec. 6056. Large employers required to report on health insurance 
              coverage.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to periods beginning after December 31, 2013.

     SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED 
                   HEALTH PLANS THROUGH CAFETERIA PLANS.

       (a) In General.--Subsection (f) of section 125 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new paragraph:
       ``(3) Certain exchange-participating qualified health plans 
     not qualified.--
       ``(A) In general.--The term `qualified benefit' shall not 
     include any qualified health plan (as defined in section 
     1301(a) of the Patient Protection and Affordable Care Act) 
     offered through an Exchange established under section 1311 of 
     such Act.
       ``(B) Exception for exchange-eligible employers.--
     Subparagraph (A) shall not apply with respect to any employee 
     if such employee's employer is a qualified employer (as 
     defined in section 1312(f)(2) of the Patient Protection and 
     Affordable Care Act) offering the employee the opportunity to 
     enroll through such an Exchange in a qualified health plan in 
     a group market.''.
       (b) Conforming Amendments.--Subsection (f) of section 125 
     of such Code is amended--
       (1) by striking ``For purposes of this section, the term'' 
     and inserting ``For purposes of this section--
       ``(1) In General.--The term'', and
       (2) by striking ``Such term shall not include'' and 
     inserting the following:
       ``(2) Long-term care insurance not qualified.--The term 
     `qualified benefit' shall not include''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2013.

                  Subtitle G--Miscellaneous Provisions

     SEC. 1551. DEFINITIONS.

       Unless specifically provided for otherwise, the definitions 
     contained in section 2791 of the Public Health Service Act 
     (42 U.S.C. 300gg-91) shall apply with respect to this title.

     SEC. 1552. TRANSPARENCY IN GOVERNMENT.

       Not later than 30 days after the date of enactment of this 
     Act, the Secretary of Health and Human Services shall publish 
     on the Internet website of the Department of Health and Human 
     Services, a list of all of the authorities provided to the 
     Secretary under this Act (and the amendments made by this 
     Act).

     SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED 
                   SUICIDE.

       (a) In General.--The Federal Government, and any State or 
     local government or health care provider that receives 
     Federal financial assistance under this Act (or under an 
     amendment made by this Act) or any health plan created under 
     this Act (or under an amendment made by this Act), may not 
     subject an individual or institutional health care entity to 
     discrimination on the basis that the entity does not provide 
     any health care item or service furnished for the purpose of 
     causing, or for the purpose of assisting in causing, the 
     death of any individual, such as by assisted suicide, 
     euthanasia, or mercy killing.
       (b) Definition.--In this section, the term ``health care 
     entity'' includes an individual physician or other health 
     care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, or any other kind of health care facility, 
     organization, or plan.
       (c) Construction and Treatment of Certain Services.--
     Nothing in subsection (a) shall be construed to apply to, or 
     to affect, any limitation relating to--
       (1) the withholding or withdrawing of medical treatment or 
     medical care;
       (2) the withholding or withdrawing of nutrition or 
     hydration;
       (3) abortion; or
       (4) the use of an item, good, benefit, or service furnished 
     for the purpose of alleviating pain or discomfort, even if 
     such use may increase the risk of death, so long as such 
     item, good, benefit, or service is not also furnished for the 
     purpose of causing, or the purpose of assisting in causing, 
     death, for any reason.
       (d) Administration.--The Office for Civil Rights of the 
     Department of Health and Human Services is designated to 
     receive complaints of discrimination based on this section.

     SEC. 1554. ACCESS TO THERAPIES.

       Notwithstanding any other provision of this Act, the 
     Secretary of Health and Human Services shall not promulgate 
     any regulation that--
       (1) creates any unreasonable barriers to the ability of 
     individuals to obtain appropriate medical care;
       (2) impedes timely access to health care services;
       (3) interferes with communications regarding a full range 
     of treatment options between the patient and the provider;
       (4) restricts the ability of health care providers to 
     provide full disclosure of all relevant information to 
     patients making health care decisions;
       (5) violates the principles of informed consent and the 
     ethical standards of health care professionals; or
       (6) limits the availability of health care treatment for 
     the full duration of a patient's medical needs.

     SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH 
                   INSURANCE PROGRAMS.

       No individual, company, business, nonprofit entity, or 
     health insurance issuer offering group or individual health 
     insurance coverage shall be required to participate in any 
     Federal health insurance program created under this Act (or 
     any amendments made by this Act), or in any Federal health 
     insurance program expanded by this Act (or any such 
     amendments), and there shall be no penalty or fine imposed 
     upon any such issuer for choosing not to participate in such 
     programs.

     SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.

       (a) Rebuttable Presumption.--Section 411(c)(4) of the Black 
     Lung Benefits Act (30 U.S.C. 921(c)(4)) is amended by 
     striking the last sentence.
       (b) Continuation of Benefits.--Section 422(l) of the Black 
     Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking 
     ``, except with respect to a claim filed under this part on 
     or after the effective date of the Black Lung Benefits 
     Amendments of 1981''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to claims filed under part B or part 
     C of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931 
     et seq.) after January 1, 2005, that are pending on or after 
     the date of enactment of this Act.

     SEC. 1557. NONDISCRIMINATION.

       (a) In General.--Except as otherwise provided for in this 
     title (or an amendment made by this title), an individual 
     shall not, on the ground prohibited under title VI of the 
     Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX 
     of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), 
     the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), 
     or section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 
     794), be excluded from participation in, be denied the 
     benefits of, or be subjected to discrimination under, any 
     health program or activity, any part of which is receiving 
     Federal financial assistance, including credits, subsidies, 
     or contracts of insurance, or under any program or activity 
     that is administered by an Executive Agency or any entity 
     established under this title (or amendments). The enforcement 
     mechanisms provided for and available under such title VI, 
     title IX, section 504, or such Age Discrimination Act shall 
     apply for purposes of violations of this subsection.
       (b) Continued Application of Laws.--Nothing in this title 
     (or an amendment made by this title) shall be construed to 
     invalidate or limit the rights, remedies, procedures, or 
     legal standards available to individuals aggrieved under 
     title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
     seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 
     2000e et seq.), title IX of the Education Amendments of 1972 
     (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation 
     Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of 
     1975 (42 U.S.C. 611 et seq.), or to supersede State laws that 
     provide additional protections against discrimination on any 
     basis described in subsection (a).
       (c) Regulations.--The Secretary may promulgate regulations 
     to implement this section.

     SEC. 1558. PROTECTIONS FOR EMPLOYEES.

       The Fair Labor Standards Act of 1938 is amended by 
     inserting after section 18B (as added by section 1512) the 
     following:

     ``SEC. 18C. PROTECTIONS FOR EMPLOYEES.

       ``(a) Prohibition.--No employer shall discharge or in any 
     manner discriminate against any employee with respect to his 
     or her compensation, terms, conditions, or other privileges 
     of employment because the employee (or an individual acting 
     at the request of the employee) has--
       ``(1) received a credit under section 36B of the Internal 
     Revenue Code of 1986 or a subsidy under section 1402 of this 
     Act;
       ``(2) provided, caused to be provided, or is about to 
     provide or cause to be provided to the employer, the Federal 
     Government, or the attorney general of a State information 
     relating to any violation of, or any act or omission the 
     employee reasonably believes to be a violation of, any 
     provision of this title (or an amendment made by this title);
       ``(3) testified or is about to testify in a proceeding 
     concerning such violation;
       ``(4) assisted or participated, or is about to assist or 
     participate, in such a proceeding; or
       ``(5) objected to, or refused to participate in, any 
     activity, policy, practice, or assigned task that the 
     employee (or other such person) reasonably believed to be in 
     violation of any provision of this title (or amendment), or 
     any order, rule, regulation, standard, or ban under this 
     title (or amendment).
       ``(b) Complaint Procedure.--
       ``(1) In general.--An employee who believes that he or she 
     has been discharged or otherwise discriminated against by any 
     employer in violation of this section may seek relief in 
     accordance with the procedures, notifications, burdens of 
     proof, remedies, and statutes of limitation set forth in 
     section 2087(b) of title 15, United States Code.
       ``(2) No limitation on rights.--Nothing in this section 
     shall be deemed to diminish the rights, privileges, or 
     remedies of any employee under any Federal or State law or 
     under any collective bargaining agreement. The rights and 
     remedies in this section may not be waived by any agreement, 
     policy, form, or condition of employment.''.

     SEC. 1559. OVERSIGHT.

       The Inspector General of the Department of Health and Human 
     Services shall have oversight authority with respect to the 
     administration and implementation of this title as it relates 
     to such Department.

[[Page 4242]]



     SEC. 1560. RULES OF CONSTRUCTION.

       (a) No Effect on Antitrust Laws.--Nothing in this title (or 
     an amendment made by this title) shall be construed to 
     modify, impair, or supersede the operation of any of the 
     antitrust laws. For the purposes of this section, the term 
     ``antitrust laws'' has the meaning given such term in 
     subsection (a) of the first section of the Clayton Act, 
     except that such term includes section 5 of the Federal Trade 
     Commission Act to the extent that such section 5 applies to 
     unfair methods of competition.
       (b) Rule of Construction Regarding Hawaii's Prepaid Health 
     Care Act.--Nothing in this title (or an amendment made by 
     this title) shall be construed to modify or limit the 
     application of the exemption for Hawaii's Prepaid Health Care 
     Act (Haw. Rev. Stat. Sec. Sec.  393-1 et seq.) as provided 
     for under section 514(b)(5) of the Employee Retirement Income 
     Security Act of 1974 (29 U.S.C. 1144(b)(5)).
       (c) Student Health Insurance Plans.--Nothing in this title 
     (or an amendment made by this title) shall be construed to 
     prohibit an institution of higher education (as such term is 
     defined for purposes of the Higher Education Act of 1965) 
     from offering a student health insurance plan, to the extent 
     that such requirement is otherwise permitted under applicable 
     Federal, State or local law.
       (d) No Effect on Existing Requirements.--Nothing in this 
     title (or an amendment made by this title, unless specified 
     by direct statutory reference) shall be construed to modify 
     any existing Federal requirement concerning the State agency 
     responsible for determining eligibility for programs 
     identified in section 1413.

     SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS 
                   AND PROTOCOLS.

       Title XXX of the Public Health Service Act (42 U.S.C. 300jj 
     et seq.) is amended by adding at the end the following:

                     ``Subtitle C--Other Provisions

     ``SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT 
                   STANDARDS AND PROTOCOLS.

       ``(a) In General.--
       ``(1) Standards and protocols.--Not later than 180 days 
     after the date of enactment of this title, the Secretary, in 
     consultation with the HIT Policy Committee and the HIT 
     Standards Committee, shall develop interoperable and secure 
     standards and protocols that facilitate enrollment of 
     individuals in Federal and State health and human services 
     programs, as determined by the Secretary.
       ``(2) Methods.--The Secretary shall facilitate enrollment 
     in such programs through methods determined appropriate by 
     the Secretary, which shall include providing individuals and 
     third parties authorized by such individuals and their 
     designees notification of eligibility and verification of 
     eligibility required under such programs.
       ``(b) Content.--The standards and protocols for electronic 
     enrollment in the Federal and State programs described in 
     subsection (a) shall allow for the following:
       ``(1) Electronic matching against existing Federal and 
     State data, including vital records, employment history, 
     enrollment systems, tax records, and other data determined 
     appropriate by the Secretary to serve as evidence of 
     eligibility and in lieu of paper-based documentation.
       ``(2) Simplification and submission of electronic 
     documentation, digitization of documents, and systems 
     verification of eligibility.
       ``(3) Reuse of stored eligibility information (including 
     documentation) to assist with retention of eligible 
     individuals.
       ``(4) Capability for individuals to apply, recertify and 
     manage their eligibility information online, including at 
     home, at points of service, and other community-based 
     locations.
       ``(5) Ability to expand the enrollment system to integrate 
     new programs, rules, and functionalities, to operate at 
     increased volume, and to apply streamlined verification and 
     eligibility processes to other Federal and State programs, as 
     appropriate.
       ``(6) Notification of eligibility, recertification, and 
     other needed communication regarding eligibility, which may 
     include communication via email and cellular phones.
       ``(7) Other functionalities necessary to provide eligibles 
     with streamlined enrollment process.
       ``(c) Approval and Notification.--With respect to any 
     standard or protocol developed under subsection (a) that has 
     been approved by the HIT Policy Committee and the HIT 
     Standards Committee, the Secretary--
       ``(1) shall notify States of such standards or protocols; 
     and
       ``(2) may require, as a condition of receiving Federal 
     funds for the health information technology investments, that 
     States or other entities incorporate such standards and 
     protocols into such investments.
       ``(d) Grants for Implementation of Appropriate Enrollment 
     HIT.--
       ``(1) In general.--The Secretary shall award grant to 
     eligible entities to develop new, and adapt existing, 
     technology systems to implement the HIT enrollment standards 
     and protocols developed under subsection (a) (referred to in 
     this subsection as `appropriate HIT technology').
       ``(2) Eligible entities.--To be eligible for a grant under 
     this subsection, an entity shall--
       ``(A) be a State, political subdivision of a State, or a 
     local governmental entity; and
       ``(B) submit to the Secretary an application at such time, 
     in such manner, and containing--
       ``(i) a plan to adopt and implement appropriate enrollment 
     technology that includes--

       ``(I) proposed reduction in maintenance costs of technology 
     systems;
       ``(II) elimination or updating of legacy systems; and
       ``(III) demonstrated collaboration with other entities that 
     may receive a grant under this section that are located in 
     the same State, political subdivision, or locality;

       ``(ii) an assurance that the entity will share such 
     appropriate enrollment technology in accordance with 
     paragraph (4); and
       ``(iii) such other information as the Secretary may 
     require.
       ``(3) Sharing.--
       ``(A) In general.--The Secretary shall ensure that 
     appropriate enrollment HIT adopted under grants under this 
     subsection is made available to other qualified State, 
     qualified political subdivisions of a State, or other 
     appropriate qualified entities (as described in subparagraph 
     (B)) at no cost.
       ``(B) Qualified entities.--The Secretary shall determine 
     what entities are qualified to receive enrollment HIT under 
     subparagraph (A), taking into consideration the 
     recommendations of the HIT Policy Committee and the HIT 
     Standards Committee.''.

     SEC. 1562. CONFORMING AMENDMENTS.

       (a) Applicability.--Section 2735 of the Public Health 
     Service Act (42 U.S.C. 300gg-21), as so redesignated by 
     section 1001(4), is amended--
       (1) by striking subsection (a);
       (2) in subsection (b)--
       (A) in paragraph (1), by striking ``1 through 3'' and 
     inserting ``1 and 2''; and
       (B) in paragraph (2)--
       (i) in subparagraph (A), by striking ``subparagraph (D)'' 
     and inserting ``subparagraph (D) or (E)'';
       (ii) by striking ``1 through 3'' and inserting ``1 and 2''; 
     and
       (iii) by adding at the end the following:
       ``(E) Election not applicable.--The election described in 
     subparagraph (A) shall not be available with respect to the 
     provisions of subpart 1.'';
       (3) in subsection (c), by striking ``1 through 3 shall not 
     apply to any group'' and inserting ``1 and 2 shall not apply 
     to any individual coverage or any group''; and
       (4) in subsection (d)--
       (A) in paragraph (1), by striking ``1 through 3 shall not 
     apply to any group'' and inserting ``1 and 2 shall not apply 
     to any individual coverage or any group'';
       (B) in paragraph (2)--
       (i) in the matter preceding subparagraph (A), by striking 
     ``1 through 3 shall not apply to any group'' and inserting 
     ``1 and 2 shall not apply to any individual coverage or any 
     group''; and
       (ii) in subparagraph (C), by inserting ``or, with respect 
     to individual coverage, under any health insurance coverage 
     maintained by the same health insurance issuer''; and
       (C) in paragraph (3), by striking ``any group'' and 
     inserting ``any individual coverage or any group''.
       (b) Definitions.--Section 2791(d) of the Public Health 
     Service Act (42 U.S.C. 300gg-91(d)) is amended by adding at 
     the end the following:
       ``(20) Qualified health plan.--The term `qualified health 
     plan' has the meaning given such term in section 1301(a) of 
     the Patient Protection and Affordable Care Act.
       ``(21) Exchange.--The term `Exchange' means an American 
     Health Benefit Exchange established under section 1311 of the 
     Patient Protection and Affordable Care Act.''.
       (c) Technical and Conforming Amendments.--Title XXVII of 
     the Public Health Service Act (42 U.S.C. 300gg et seq.) is 
     amended--
       (1) in section 2704 (42 U.S.C. 300gg), as so redesignated 
     by section 1201(2)--
       (A) in subsection (c)--
       (i) in paragraph (2), by striking ``group health plan'' 
     each place that such term appears and inserting ``group or 
     individual health plan''; and
       (ii) in paragraph (3)--

       (I) by striking ``group health insurance'' each place that 
     such term appears and inserting ``group or individual health 
     insurance''; and
       (II) in subparagraph (D), by striking ``small or large'' 
     and inserting ``individual or group'';

       (B) in subsection (d), by striking ``group health 
     insurance'' each place that such term appears and inserting 
     ``group or individual health insurance''; and
       (C) in subsection (e)(1)(A), by striking ``group health 
     insurance'' and inserting ``group or individual health 
     insurance'';
       (2) by striking the second heading for subpart 2 of part A 
     (relating to other requirements);
       (3) in section 2725 (42 U.S.C. 300gg-4), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``health insurance 
     issuer offering group health insurance coverage'' and 
     inserting ``health insurance issuer offering group or 
     individual health insurance coverage'';
       (B) in subsection (b)--
       (i) by striking ``health insurance issuer offering group 
     health insurance coverage in connection with a group health 
     plan'' in the matter preceding paragraph (1) and inserting 
     ``health insurance issuer offering group or individual health 
     insurance coverage''; and
       (ii) in paragraph (1), by striking ``plan'' and inserting 
     ``plan or coverage'';
       (C) in subsection (c)--
       (i) in paragraph (2), by striking ``group health insurance 
     coverage offered by a health insurance issuer'' and inserting 
     ``health insurance issuer offering group or individual health 
     insurance coverage''; and
       (ii) in paragraph (3), by striking ``issuer'' and inserting 
     ``health insurance issuer''; and
       (D) in subsection (e), by striking ``health insurance 
     issuer offering group health insurance

[[Page 4243]]

     coverage'' and inserting ``health insurance issuer offering 
     group or individual health insurance coverage'';
       (4) in section 2726 (42 U.S.C. 300gg-5), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage'';
       (B) in subsection (b), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage''; and
       (C) in subsection (c)--
       (i) in paragraph (1), by striking ``(and group health 
     insurance coverage offered in connection with a group health 
     plan)'' and inserting ``and a health insurance issuer 
     offering group or individual health insurance coverage'';
       (ii) in paragraph (2), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage'';
       (5) in section 2727 (42 U.S.C. 300gg-6), as so redesignated 
     by section 1001(2), by striking ``health insurance issuers 
     providing health insurance coverage in connection with group 
     health plans'' and inserting ``and health insurance issuers 
     offering group or individual health insurance coverage'';
       (6) in section 2728 (42 U.S.C. 300gg-7), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``health insurance 
     coverage offered in connection with such plan'' and inserting 
     ``individual health insurance coverage'';
       (B) in subsection (b)--
       (i) in paragraph (1), by striking ``or a health insurance 
     issuer that provides health insurance coverage in connection 
     with a group health plan'' and inserting ``or a health 
     insurance issuer that offers group or individual health 
     insurance coverage'';
       (ii) in paragraph (2), by striking ``health insurance 
     coverage offered in connection with the plan'' and inserting 
     ``individual health insurance coverage''; and
       (iii) in paragraph (3), by striking ``health insurance 
     coverage offered by an issuer in connection with such plan'' 
     and inserting ``individual health insurance coverage'';
       (C) in subsection (c), by striking ``health insurance 
     issuer providing health insurance coverage in connection with 
     a group health plan'' and inserting ``health insurance issuer 
     that offers group or individual health insurance coverage''; 
     and
       (D) in subsection (e)(1), by striking ``health insurance 
     coverage offered in connection with such a plan'' and 
     inserting ``individual health insurance coverage'';
       (7) by striking the heading for subpart 3;
       (8) in section 2731 (42 U.S.C. 300gg-11), as so 
     redesignated by section 1001(3)--
       (A) by striking the section heading and all that follows 
     through subsection (b);
       (B) in subsection (c)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``small group'' and inserting ``group and individual''; and
       (II) in subparagraph (B)--

       (aa) in the matter preceding clause (i), by inserting ``and 
     individuals'' after ``employers'';
       (bb) in clause (i), by inserting ``or any additional 
     individuals'' after ``additional groups''; and
       (cc) in clause (ii), by striking ``without regard to the 
     claims experience of those employers and their employees (and 
     their dependents) or any health status-related factor 
     relating to such'' and inserting ``and individuals without 
     regard to the claims experience of those individuals, 
     employers and their employees (and their dependents) or any 
     health status-related factor relating to such individuals''; 
     and
       (ii) in paragraph (2), by striking ``small group'' and 
     inserting ``group or individual'';
       (C) in subsection (d)--
       (i) by striking ``small group'' each place that such 
     appears and inserting ``group or individual''; and
       (ii) in paragraph (1)(B)--

       (I) by striking ``all employers'' and inserting ``all 
     employers and individuals'';
       (II) by striking ``those employers'' and inserting ``those 
     individuals, employers''; and
       (III) by striking ``such employees'' and inserting ``such 
     individuals, employees'';

       (D) by striking subsection (e);
       (E) by striking subsection (f); and
       (F) by transferring such section (as amended by this 
     paragraph) to appear at the end of section 2702 (as added by 
     section 1001(4));
       (9) in section 2732 (42 U.S.C. 300gg-12), as so 
     redesignated by section 1001(3)--
       (A) by striking the section heading and all that follows 
     through subsection (a);
       (B) in subsection (b)--
       (i) in the matter preceding paragraph (1), by striking 
     ``group health plan in the small or large group market'' and 
     inserting ``health insurance coverage offered in the group or 
     individual market'';
       (ii) in paragraph (1), by inserting ``, or individual, as 
     applicable,'' after ``plan sponsor'';
       (iii) in paragraph (2), by inserting ``, or individual, as 
     applicable,'' after ``plan sponsor''; and
       (iv) by striking paragraph (3) and inserting the following:
       ``(3) Violation of participation or contribution rates.--In 
     the case of a group health plan, the plan sponsor has failed 
     to comply with a material plan provision relating to employer 
     contribution or group participation rules, pursuant to 
     applicable State law.'';
       (C) in subsection (c)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``group health insurance coverage offered in the small or 
     large group market'' and inserting ``group or individual 
     health insurance coverage'';
       (II) in subparagraph (A), by inserting ``or individual, as 
     applicable,'' after ``plan sponsor'';
       (III) in subparagraph (B)--

       (aa) by inserting ``or individual, as applicable,'' after 
     ``plan sponsor''; and
       (bb) by inserting ``or individual health insurance 
     coverage''; and

       (IV) in subparagraph (C), by inserting ``or individuals, as 
     applicable,'' after ``those sponsors''; and

       (ii) in paragraph (2)(A)--

       (I) in the matter preceding clause (i), by striking ``small 
     group market or the large group market, or both markets,'' 
     and inserting ``individual or group market, or all 
     markets,''; and
       (II) in clause (i), by inserting ``or individual, as 
     applicable,'' after ``plan sponsor''; and

       (D) by transferring such section (as amended by this 
     paragraph) to appear at the end of section 2703 (as added by 
     section 1001(4));
       (10) in section 2733 (42 U.S.C. 300gg-13), as so 
     redesignated by section 1001(4)--
       (A) in subsection (a)--
       (i) in the matter preceding paragraph (1), by striking 
     ``small employer'' and inserting ``small employer or an 
     individual'';
       (ii) in paragraph (1), by inserting ``, or individual, as 
     applicable,'' after ``employer'' each place that such 
     appears; and
       (iii) in paragraph (2), by striking ``small employer'' and 
     inserting ``employer, or individual, as applicable,'';
       (B) in subsection (b)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``small employer'' and inserting ``employer, or individual, 
     as applicable,'';
       (II) in subparagraph (A), by adding ``and'' at the end;
       (III) by striking subparagraphs (B) and (C); and
       (IV) in subparagraph (D)--

       (aa) by inserting ``, or individual, as applicable,'' after 
     ``employer''; and
       (bb) by redesignating such subparagraph as subparagraph 
     (B);
       (ii) in paragraph (2)--

       (I) by striking ``small employers'' each place that such 
     term appears and inserting ``employers, or individuals, as 
     applicable,''; and
       (II) by striking ``small employer'' and inserting 
     ``employer, or individual, as applicable,''; and

       (C) by redesignating such section (as amended by this 
     paragraph) as section 2709 and transferring such section to 
     appear after section 2708 (as added by section 1001(5));
       (11) by redesignating subpart 4 as subpart 2;
       (12) in section 2735 (42 U.S.C. 300gg-21), as so 
     redesignated by section 1001(4)--
       (A) by striking subsection (a);
       (B) by striking ``subparts 1 through 3'' each place that 
     such appears and inserting ``subpart 1'';
       (C) by redesignating subsections (b) through (e) as 
     subsections (a) through (d), respectively; and
       (D) by redesignating such section (as amended by this 
     paragraph) as section 2722;
       (13) in section 2736 (42 U.S.C. 300gg-22), as so 
     redesignated by section 1001(4)--
       (A) in subsection (a)--
       (i) in paragraph (1), by striking ``small or large group 
     markets'' and inserting ``individual or group market''; and
       (ii) in paragraph (2), by inserting ``or individual health 
     insurance coverage'' after ``group health plans'';
       (B) in subsection (b)(1)(B), by inserting ``individual 
     health insurance coverage or'' after ``respect to''; and
       (C) by redesignating such section (as amended by this 
     paragraph) as section 2723;
       (14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so 
     redesignated by section 1001(4)--
       (A) by inserting ``individual or'' before ``group health 
     insurance''; and
       (B) by redesignating such section(as amended by this 
     paragraph) as section 2724;
       (15) in section 2762 (42 U.S.C. 300gg-62)--
       (A) in the section heading by inserting ``AND APPLICATION'' 
     before the period; and
       (B) by adding at the end the following:
       ``(c) Application of Part A Provisions.--
       ``(1) In general.--The provisions of part A shall apply to 
     health insurance issuers providing health insurance coverage 
     in the individual market in a State as provided for in such 
     part.
       ``(2) Clarification.--To the extent that any provision of 
     this part conflicts with a provision of part A with respect 
     to health insurance issuers providing health insurance 
     coverage in the individual market in a State, the provisions 
     of such part A shall apply.''; and
       (16) in section 2791(e) (42 U.S.C. 300gg-91(e))--
       (A) in paragraph (2), by striking ``51'' and inserting 
     ``101''; and
       (B) in paragraph (4)--
       (i) by striking ``at least 2'' each place that such appears 
     and inserting ``at least 1''; and
       (ii) by striking ``50'' and inserting ``100''.
       (d) Application.--Notwithstanding any other provision of 
     the Patient Protection and Affordable Care Act, nothing in 
     such Act (or an

[[Page 4244]]

     amendment made by such Act) shall be construed to--
       (1) prohibit (or authorize the Secretary of Health and 
     Human Services to promulgate regulations that prohibit) a 
     group health plan or health insurance issuer from carrying 
     out utilization management techniques that are commonly used 
     as of the date of enactment of this Act; or
       (2) restrict the application of the amendments made by this 
     subtitle.
       (e) Technical Amendment to the Employee Retirement Income 
     Security Act of 1974.--Subpart B of part 7 of subtitle A of 
     title I of the Employee Retirement Income Security Act of 
     1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the 
     end the following:

     ``SEC. 715. ADDITIONAL MARKET REFORMS.

       ``(a) General Rule.--Except as provided in subsection (b)--
       ``(1) the provisions of part A of title XXVII of the Public 
     Health Service Act (as amended by the Patient Protection and 
     Affordable Care Act) shall apply to group health plans, and 
     health insurance issuers providing health insurance coverage 
     in connection with group health plans, as if included in this 
     subpart; and
       ``(2) to the extent that any provision of this part 
     conflicts with a provision of such part A with respect to 
     group health plans, or health insurance issuers providing 
     health insurance coverage in connection with group health 
     plans, the provisions of such part A shall apply.
       ``(b) Exception.--Notwithstanding subsection (a), the 
     provisions of sections 2716 and 2718 of title XXVII of the 
     Public Health Service Act (as amended by the Patient 
     Protection and Affordable Care Act) shall not apply with 
     respect to self-insured group health plans, and the 
     provisions of this part shall continue to apply to such plans 
     as if such sections of the Public Health Service Act (as so 
     amended) had not been enacted.''.
       (f) Technical Amendment to the Internal Revenue Code of 
     1986.--Subchapter B of chapter 100 of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following:

     ``SEC. 9815. ADDITIONAL MARKET REFORMS.

       ``(a) General Rule.--Except as provided in subsection (b)--
       ``(1) the provisions of part A of title XXVII of the Public 
     Health Service Act (as amended by the Patient Protection and 
     Affordable Care Act) shall apply to group health plans, and 
     health insurance issuers providing health insurance coverage 
     in connection with group health plans, as if included in this 
     subchapter; and
       ``(2) to the extent that any provision of this subchapter 
     conflicts with a provision of such part A with respect to 
     group health plans, or health insurance issuers providing 
     health insurance coverage in connection with group health 
     plans, the provisions of such part A shall apply.
       ``(b) Exception.--Notwithstanding subsection (a), the 
     provisions of sections 2716 and 2718 of title XXVII of the 
     Public Health Service Act (as amended by the Patient 
     Protection and Affordable Care Act) shall not apply with 
     respect to self-insured group health plans, and the 
     provisions of this subchapter shall continue to apply to such 
     plans as if such sections of the Public Health Service Act 
     (as so amended) had not been enacted.''.

     SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL 
                   RESPONSIBILITY.

       (a) Findings.--The Senate makes the following findings:
       (1) Based on Congressional Budget Office (CBO) estimates, 
     this Act will reduce the Federal deficit between 2010 and 
     2019.
       (2) CBO projects this Act will continue to reduce budget 
     deficits after 2019.
       (3) Based on CBO estimates, this Act will extend the 
     solvency of the Medicare HI Trust Fund.
       (4) This Act will increase the surplus in the Social 
     Security Trust Fund, which should be reserved to strengthen 
     the finances of Social Security.
       (5) The initial net savings generated by the Community 
     Living Assistance Services and Supports (CLASS) program are 
     necessary to ensure the long-term solvency of that program.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that--
       (1) the additional surplus in the Social Security Trust 
     Fund generated by this Act should be reserved for Social 
     Security and not spent in this Act for other purposes; and
       (2) the net savings generated by the CLASS program should 
     be reserved for the CLASS program and not spent in this Act 
     for other purposes.

                   TITLE II--ROLE OF PUBLIC PROGRAMS

                Subtitle A--Improved Access to Medicaid

     SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME 
                   POPULATIONS.

       (a) Coverage for Individuals With Income at or Below 133 
     Percent of the Poverty Line.--
       (1) Beginning 2014.--Section 1902(a)(10)(A)(i) of the 
     Social Security Act (42 U.S.C. 1396a) is amended--
       (A) by striking ``or'' at the end of subclause (VI);
       (B) by adding ``or'' at the end of subclause (VII); and
       (C) by inserting after subclause (VII) the following:

       ``(VIII) beginning January 1, 2014, who are under 65 years 
     of age, not pregnant, not entitled to, or enrolled for, 
     benefits under part A of title XVIII, or enrolled for 
     benefits under part B of title XVIII, and are not described 
     in a previous subclause of this clause, and whose income (as 
     determined under subsection (e)(14)) does not exceed 133 
     percent of the poverty line (as defined in section 
     2110(c)(5)) applicable to a family of the size involved, 
     subject to subsection (k);''.

       (2) Provision of at least minimum essential coverage.--
       (A) In general.--Section 1902 of such Act (42 U.S.C. 1396a) 
     is amended by inserting after subsection (j) the following:
       ``(k)(1) The medical assistance provided to an individual 
     described in subclause (VIII) of subsection (a)(10)(A)(i) 
     shall consist of benchmark coverage described in section 
     1937(b)(1) or benchmark equivalent coverage described in 
     section 1937(b)(2). Such medical assistance shall be provided 
     subject to the requirements of section 1937, without regard 
     to whether a State otherwise has elected the option to 
     provide medical assistance through coverage under that 
     section, unless an individual described in subclause (VIII) 
     of subsection (a)(10)(A)(i) is also an individual for whom, 
     under subparagraph (B) of section 1937(a)(2), the State may 
     not require enrollment in benchmark coverage described in 
     subsection (b)(1) of section 1937 or benchmark equivalent 
     coverage described in subsection (b)(2) of that section.''.
       (B) Conforming amendment.--Section 1903(i) of the Social 
     Security Act, as amended by section 6402(c), is amended--
       (i) in paragraph (24), by striking ``or'' at the end;
       (ii) in paragraph (25), by striking the period and 
     inserting ``; or''; and
       (iii) by adding at the end the following:
       ``(26) with respect to any amounts expended for medical 
     assistance for individuals described in subclause (VIII) of 
     subsection (a)(10)(A)(i) other than medical assistance 
     provided through benchmark coverage described in section 
     1937(b)(1) or benchmark equivalent coverage described in 
     section 1937(b)(2).''.
       (3) Federal funding for cost of covering newly eligible 
     individuals.--Section 1905 of the Social Security Act (42 
     U.S.C. 1396d), is amended--
       (A) in subsection (b), in the first sentence, by inserting 
     ``subsection (y) and'' before ``section 1933(d)''; and
       (B) by adding at the end the following new subsection:
       ``(y) Increased FMAP for Medical Assistance for Newly 
     Eligible Mandatory Individuals.--
       ``(1) Amount of increase.--
       ``(A) 100 percent fmap.--During the period that begins on 
     January 1, 2014, and ends on December 31, 2016, 
     notwithstanding subsection (b), the Federal medical 
     assistance percentage determined for a State that is one of 
     the 50 States or the District of Columbia for each fiscal 
     year occurring during that period with respect to amounts 
     expended for medical assistance for newly eligible 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i) shall be equal to 100 percent.
       ``(B) 2017 and 2018.--
       ``(i) In general.--During the period that begins on January 
     1, 2017, and ends on December 31, 2018, notwithstanding 
     subsection (b) and subject to subparagraph (D), the Federal 
     medical assistance percentage determined for a State that is 
     one of the 50 States or the District of Columbia for each 
     fiscal year occurring during that period with respect to 
     amounts expended for medical assistance for newly eligible 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i), shall be increased by the applicable 
     percentage point increase specified in clause (ii) for the 
     quarter and the State.
       ``(ii) Applicable percentage point increase.--

       ``(I) In general.--For purposes of clause (i), the 
     applicable percentage point increase for a quarter is the 
     following:


----------------------------------------------------------------------------------------------------------------
                                       If the State is an expansion State,    If the State is not an expansion
    ``For any fiscal year quarter        the applicable percentage point      State, the applicable percentage
   occurring in the calendar year:                increase is:                       point increase is:
----------------------------------------------------------------------------------------------------------------
2017                                  30.3                                  34.3
----------------------------------------------------------------------------------------------------------------
2018                                  31.3                                  33.3
----------------------------------------------------------------------------------------------------------------

       ``(II) Expansion state defined.--For purposes of the table 
     in subclause (I), a State is an expansion State if, on the 
     date of the enactment of the Patient Protection and 
     Affordable Care Act, the State offers health benefits 
     coverage statewide to parents and nonpregnant, childless 
     adults whose income is at least 100 percent of the poverty 
     line, that is not dependent on access to employer coverage, 
     employer contribution, or employment and is not limited to 
     premium assistance, hospital-only benefits, a high deductible 
     health plan, or alternative benefits under a

[[Page 4245]]

     demonstration program authorized under section 1938. A State 
     that offers health benefits coverage to only parents or only 
     nonpregnant childless adults described in the preceding 
     sentence shall not be considered to be an expansion State.

       ``(C) 2019 and succeeding years.--Beginning January 1, 
     2019, notwithstanding subsection (b) but subject to 
     subparagraph (D), the Federal medical assistance percentage 
     determined for a State that is one of the 50 States or the 
     District of Columbia for each fiscal year quarter occurring 
     during that period with respect to amounts expended for 
     medical assistance for newly eligible individuals described 
     in subclause (VIII) of section 1902(a)(10)(A)(i), shall be 
     increased by 32.3 percentage points.
       ``(D) Limitation.--The Federal medical assistance 
     percentage determined for a State under subparagraph (B) or 
     (C) shall in no case be more than 95 percent.
       ``(2) Definitions.--In this subsection:
       ``(A) Newly eligible.--The term `newly eligible' means, 
     with respect to an individual described in subclause (VIII) 
     of section 1902(a)(10)(A)(i), an individual who is not under 
     19 years of age (or such higher age as the State may have 
     elected) and who, on the date of enactment of the Patient 
     Protection and Affordable Care Act, is not eligible under the 
     State plan or under a waiver of the plan for full benefits or 
     for benchmark coverage described in subparagraph (A), (B), or 
     (C) of section 1937(b)(1) or benchmark equivalent coverage 
     described in section 1937(b)(2) that has an aggregate 
     actuarial value that is at least actuarially equivalent to 
     benchmark coverage described in subparagraph (A), (B), or (C) 
     of section 1937(b)(1), or is eligible but not enrolled (or is 
     on a waiting list) for such benefits or coverage through a 
     waiver under the plan that has a capped or limited enrollment 
     that is full.
       ``(B) Full benefits.--The term `full benefits' means, with 
     respect to an individual, medical assistance for all services 
     covered under the State plan under this title that is not 
     less in amount, duration, or scope, or is determined by the 
     Secretary to be substantially equivalent, to the medical 
     assistance available for an individual described in section 
     1902(a)(10)(A)(i).''.
       (4) State options to offer coverage earlier and presumptive 
     eligibility; children required to have coverage for parents 
     to be eligible.--
       (A) In general.--Subsection (k) of section 1902 of the 
     Social Security Act (as added by paragraph (2)), is amended 
     by inserting after paragraph (1) the following:
       ``(2) Beginning with the first day of any fiscal year 
     quarter that begins on or after January 1, 2011, and before 
     January 1, 2014, a State may elect through a State plan 
     amendment to provide medical assistance to individuals who 
     would be described in subclause (VIII) of subsection 
     (a)(10)(A)(i) if that subclause were effective before January 
     1, 2014. A State may elect to phase-in the extension of 
     eligibility for medical assistance to such individuals based 
     on income, so long as the State does not extend such 
     eligibility to individuals described in such subclause with 
     higher income before making individuals described in such 
     subclause with lower income eligible for medical assistance.
       ``(3) If an individual described in subclause (VIII) of 
     subsection (a)(10)(A)(i) is the parent of a child who is 
     under 19 years of age (or such higher age as the State may 
     have elected) who is eligible for medical assistance under 
     the State plan or under a waiver of such plan (under that 
     subclause or under a State plan amendment under paragraph 
     (2), the individual may not be enrolled under the State plan 
     unless the individual's child is enrolled under the State 
     plan or under a waiver of the plan or is enrolled in other 
     health insurance coverage. For purposes of the preceding 
     sentence, the term `parent' includes an individual treated as 
     a caretaker relative for purposes of carrying out section 
     1931.''.
       (B) Presumptive eligibility.--Section 1920 of the Social 
     Security Act (42 U.S.C. 1396r-1) is amended by adding at the 
     end the following:
       ``(e) If the State has elected the option to provide a 
     presumptive eligibility period under this section or section 
     1920A, the State may elect to provide a presumptive 
     eligibility period (as defined in subsection (b)(1)) for 
     individuals who are eligible for medical assistance under 
     clause (i)(VIII) of subsection (a)(10)(A) or section 1931 in 
     the same manner as the State provides for such a period under 
     this section or section 1920A, subject to such guidance as 
     the Secretary shall establish.''.
       (5) Conforming amendments.--
       (A) Section 1902(a)(10) of such Act (42 U.S.C. 
     1396a(a)(10)) is amended in the matter following subparagraph 
     (G), by striking ``and (XIV)'' and inserting ``(XIV)'' and by 
     inserting ``and (XV) the medical assistance made available to 
     an individual described in subparagraph (A)(i)(VIII) shall be 
     limited to medical assistance described in subsection 
     (k)(1)'' before the semicolon.
       (B) Section 1902(l)(2)(C) of such Act (42 U.S.C. 
     1396a(l)(2)(C)) is amended by striking ``100'' and inserting 
     ``133''.
       (C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is 
     amended in the matter preceding paragraph (1)--
       (i) by striking ``or'' at the end of clause (xii);
       (ii) by inserting ``or'' at the end of clause (xiii); and
       (iii) by inserting after clause (xiii) the following:
       ``(xiv) individuals described in section 
     1902(a)(10)(A)(i)(VIII),''.
       (D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
     is amended by inserting ``1902(a)(10)(A)(i)(VIII),'' after 
     ``1902(a)(10)(A)(i)(VII),''.
       (E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u-
     7(a)(1)(B)) is amended by inserting ``subclause (VIII) of 
     section 1902(a)(10)(A)(i) or under'' after ``eligible 
     under''.
       (b) Maintenance of Medicaid Income Eligibility.--Section 
     1902 of the Social Security Act (42 U.S.C. 1396a) is 
     amended--
       (1) in subsection (a)--
       (A) by striking ``and'' at the end of paragraph (72);
       (B) by striking the period at the end of paragraph (73) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (73) the following new 
     paragraph:
       ``(74) provide for maintenance of effort under the State 
     plan or under any waiver of the plan in accordance with 
     subsection (gg).''; and
       (2) by adding at the end the following new subsection:
       ``(gg) Maintenance of Effort.--
       ``(1) General requirement to maintain eligibility standards 
     until state exchange is fully operational.--Subject to the 
     succeeding paragraphs of this subsection, during the period 
     that begins on the date of enactment of the Patient 
     Protection and Affordable Care Act and ends on the date on 
     which the Secretary determines that an Exchange established 
     by the State under section 1311 of the Patient Protection and 
     Affordable Care Act is fully operational, as a condition for 
     receiving any Federal payments under section 1903(a) for 
     calendar quarters occurring during such period, a State shall 
     not have in effect eligibility standards, methodologies, or 
     procedures under the State plan under this title or under any 
     waiver of such plan that is in effect during that period, 
     that are more restrictive than the eligibility standards, 
     methodologies, or procedures, respectively, under the plan or 
     waiver that are in effect on the date of enactment of the 
     Patient Protection and Affordable Care Act.
       ``(2) Continuation of eligibility standards for children 
     until october 1, 2019.--The requirement under paragraph (1) 
     shall continue to apply to a State through September 30, 
     2019, with respect to the eligibility standards, 
     methodologies, and procedures under the State plan under this 
     title or under any waiver of such plan that are applicable to 
     determining the eligibility for medical assistance of any 
     child who is under 19 years of age (or such higher age as the 
     State may have elected).
       ``(3) Nonapplication.--During the period that begins on 
     January 1, 2011, and ends on December 31, 2013, the 
     requirement under paragraph (1) shall not apply to a State 
     with respect to nonpregnant, nondisabled adults who are 
     eligible for medical assistance under the State plan or under 
     a waiver of the plan at the option of the State and whose 
     income exceeds 133 percent of the poverty line (as defined in 
     section 2110(c)(5)) applicable to a family of the size 
     involved if, on or after December 31, 2010, the State 
     certifies to the Secretary that, with respect to the State 
     fiscal year during which the certification is made, the State 
     has a budget deficit, or with respect to the succeeding State 
     fiscal year, the State is projected to have a budget deficit. 
     Upon submission of such a certification to the Secretary, the 
     requirement under paragraph (1) shall not apply to the State 
     with respect to any remaining portion of the period described 
     in the preceding sentence.
       ``(4) Determination of compliance.--
       ``(A) States shall apply modified gross income.--A State's 
     determination of income in accordance with subsection (e)(14) 
     shall not be considered to be eligibility standards, 
     methodologies, or procedures that are more restrictive than 
     the standards, methodologies, or procedures in effect under 
     the State plan or under a waiver of the plan on the date of 
     enactment of the Patient Protection and Affordable Care Act 
     for purposes of determining compliance with the requirements 
     of paragraph (1), (2), or (3).
       ``(B) States may expand eligibility or move waivered 
     populations into coverage under the state plan.--With respect 
     to any period applicable under paragraph (1), (2), or (3), a 
     State that applies eligibility standards, methodologies, or 
     procedures under the State plan under this title or under any 
     waiver of the plan that are less restrictive than the 
     eligibility standards, methodologies, or procedures, applied 
     under the State plan or under a waiver of the plan on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act, or that makes individuals who, on such date of 
     enactment, are eligible for medical assistance under a waiver 
     of the State plan, after such date of enactment eligible for 
     medical assistance through a State plan amendment with an 
     income eligibility level that is not less than the income 
     eligibility level that applied under the waiver, or as a 
     result of the application of subclause (VIII) of section 
     1902(a)(10)(A)(i), shall not be considered to have in effect 
     eligibility standards, methodologies, or procedures that are 
     more restrictive than the standards, methodologies, or 
     procedures in effect under the State plan or under a waiver 
     of the plan on the date of enactment of the Patient 
     Protection and Affordable Care Act for purposes of 
     determining compliance with the requirements of paragraph 
     (1), (2), or (3).''.
       (c) Medicaid Benchmark Benefits Must Consist of at Least 
     Minimum Essential Coverage.--Section 1937(b) of such Act (42 
     U.S.C. 1396u-7(b)) is amended--
       (1) in paragraph (1), in the matter preceding subparagraph 
     (A), by inserting ``subject to paragraphs (5) and (6),'' 
     before ``each'';
       (2) in paragraph (2)--

[[Page 4246]]

       (A) in the matter preceding subparagraph (A), by inserting 
     ``subject to paragraphs (5) and (6)'' after ``subsection 
     (a)(1),'';
       (B) in subparagraph (A)--
       (i) by redesignating clauses (iv) and (v) as clauses (vi) 
     and (vii), respectively; and
       (ii) by inserting after clause (iii), the following:
       ``(iv) Coverage of prescription drugs.
       ``(v) Mental health services.''; and
       (C) in subparagraph (C)--
       (i) by striking clauses (i) and (ii); and
       (ii) by redesignating clauses (iii) and (iv) as clauses (i) 
     and (ii), respectively; and
       (3) by adding at the end the following new paragraphs:
       ``(5) Minimum standards.--Effective January 1, 2014, any 
     benchmark benefit package under paragraph (1) or benchmark 
     equivalent coverage under paragraph (2) must provide at least 
     essential health benefits as described in section 1302(b) of 
     the Patient Protection and Affordable Care Act.
       ``(6) Mental health services parity.--
       ``(A) In general.--In the case of any benchmark benefit 
     package under paragraph (1) or benchmark equivalent coverage 
     under paragraph (2) that is offered by an entity that is not 
     a medicaid managed care organization and that provides both 
     medical and surgical benefits and mental health or substance 
     use disorder benefits, the entity shall ensure that the 
     financial requirements and treatment limitations applicable 
     to such mental health or substance use disorder benefits 
     comply with the requirements of section 2705(a) of the Public 
     Health Service Act in the same manner as such requirements 
     apply to a group health plan.
       ``(B) Deemed compliance.--Coverage provided with respect to 
     an individual described in section 1905(a)(4)(B) and covered 
     under the State plan under section 1902(a)(10)(A) of the 
     services described in section 1905(a)(4)(B) (relating to 
     early and periodic screening, diagnostic, and treatment 
     services defined in section 1905(r)) and provided in 
     accordance with section 1902(a)(43), shall be deemed to 
     satisfy the requirements of subparagraph (A).''.
       (d) Annual Reports on Medicaid Enrollment.--
       (1) State reports.--Section 1902(a) of the Social Security 
     Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is 
     amended--
       (A) by striking ``and'' at the end of paragraph (73);
       (B) by striking the period at the end of paragraph (74) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (74) the following new 
     paragraph:
       ``(75) provide that, beginning January 2015, and annually 
     thereafter, the State shall submit a report to the Secretary 
     that contains--
       ``(A) the total number of enrolled and newly enrolled 
     individuals in the State plan or under a waiver of the plan 
     for the fiscal year ending on September 30 of the preceding 
     calendar year, disaggregated by population, including 
     children, parents, nonpregnant childless adults, disabled 
     individuals, elderly individuals, and such other categories 
     or sub-categories of individuals eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     as the Secretary may require;
       ``(B) a description, which may be specified by population, 
     of the outreach and enrollment processes used by the State 
     during such fiscal year; and
       ``(C) any other data reporting determined necessary by the 
     Secretary to monitor enrollment and retention of individuals 
     eligible for medical assistance under the State plan or under 
     a waiver of the plan.''.
       (2) Reports to congress.--Beginning April 2015, and 
     annually thereafter, the Secretary of Health and Human 
     Services shall submit a report to the appropriate committees 
     of Congress on the total enrollment and new enrollment in 
     Medicaid for the fiscal year ending on September 30 of the 
     preceding calendar year on a national and State-by-State 
     basis, and shall include in each such report such 
     recommendations for administrative or legislative changes to 
     improve enrollment in the Medicaid program as the Secretary 
     determines appropriate.
       (e) State Option for Coverage for Individuals With Income 
     That Exceeds 133 Percent of the Poverty Line.--
       (1) Coverage as optional categorically needy group.--
     Section 1902 of the Social Security Act (42 U.S.C. 1396a) is 
     amended--
       (A) in subsection (a)(10)(A)(ii)--
       (i) in subclause (XVIII), by striking ``or'' at the end;
       (ii) in subclause (XIX), by adding ``or'' at the end; and
       (iii) by adding at the end the following new subclause:

       ``(XX) beginning January 1, 2014, who are under 65 years of 
     age and are not described in or enrolled under a previous 
     subclause of this clause, and whose income (as determined 
     under subsection (e)(14)) exceeds 133 percent of the poverty 
     line (as defined in section 2110(c)(5)) applicable to a 
     family of the size involved but does not exceed the highest 
     income eligibility level established under the State plan or 
     under a waiver of the plan, subject to subsection (hh);'' and

       (B) by adding at the end the following new subsection:
       ``(hh)(1) A State may elect to phase-in the extension of 
     eligibility for medical assistance to individuals described 
     in subclause (XX) of subsection (a)(10)(A)(ii) based on the 
     categorical group (including nonpregnant childless adults) or 
     income, so long as the State does not extend such eligibility 
     to individuals described in such subclause with higher income 
     before making individuals described in such subclause with 
     lower income eligible for medical assistance.
       ``(2) If an individual described in subclause (XX) of 
     subsection (a)(10)(A)(ii) is the parent of a child who is 
     under 19 years of age (or such higher age as the State may 
     have elected) who is eligible for medical assistance under 
     the State plan or under a waiver of such plan, the individual 
     may not be enrolled under the State plan unless the 
     individual's child is enrolled under the State plan or under 
     a waiver of the plan or is enrolled in other health insurance 
     coverage. For purposes of the preceding sentence, the term 
     `parent' includes an individual treated as a caretaker 
     relative for purposes of carrying out section 1931.''.
       (2) Conforming amendments.--
       (A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as 
     amended by subsection (a)(5)(C), is amended in the matter 
     preceding paragraph (1)--
       (i) by striking ``or'' at the end of clause (xiii);
       (ii) by inserting ``or'' at the end of clause (xiv); and
       (iii) by inserting after clause (xiv) the following:
       ``(xv) individuals described in section 
     1902(a)(10)(A)(ii)(XX),''.
       (B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
     is amended by inserting ``1902(a)(10)(A)(ii)(XX),'' after 
     ``1902(a)(10)(A)(ii)(XIX),''.
       (C) Section 1920(e) of such Act (42 U.S.C. 1396r-1(e)), as 
     added by subsection (a)(4)(B), is amended by inserting ``or 
     clause (ii)(XX)'' after ``clause (i)(VIII)''.

     SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING 
                   MODIFIED GROSS INCOME.

       (a) In General.--Section 1902(e) of the Social Security Act 
     (42 U.S.C. 1396a(e)) is amended by adding at the end the 
     following:
       ``(14) Income determined using modified gross income.--
       ``(A) In general.--Notwithstanding subsection (r) or any 
     other provision of this title, except as provided in 
     subparagraph (D), for purposes of determining income 
     eligibility for medical assistance under the State plan or 
     under any waiver of such plan and for any other purpose 
     applicable under the plan or waiver for which a determination 
     of income is required, including with respect to the 
     imposition of premiums and cost-sharing, a State shall use 
     the modified gross income of an individual and, in the case 
     of an individual in a family greater than 1, the household 
     income of such family. A State shall establish income 
     eligibility thresholds for populations to be eligible for 
     medical assistance under the State plan or a waiver of the 
     plan using modified gross income and household income that 
     are not less than the effective income eligibility levels 
     that applied under the State plan or waiver on the date of 
     enactment of the Patient Protection and Affordable Care Act. 
     For purposes of complying with the maintenance of effort 
     requirements under subsection (gg) during the transition to 
     modified gross income and household income, a State shall, 
     working with the Secretary, establish an equivalent income 
     test that ensures individuals eligible for medical assistance 
     under the State plan or under a waiver of the plan on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act, do not lose coverage under the State plan or under 
     a waiver of the plan. The Secretary may waive such provisions 
     of this title and title XXI as are necessary to ensure that 
     States establish income and eligibility determination systems 
     that protect beneficiaries.
       ``(B) No income or expense disregards.--No type of expense, 
     block, or other income disregard shall be applied by a State 
     to determine income eligibility for medical assistance under 
     the State plan or under any waiver of such plan or for any 
     other purpose applicable under the plan or waiver for which a 
     determination of income is required.
       ``(C) No assets test.--A State shall not apply any assets 
     or resources test for purposes of determining eligibility for 
     medical assistance under the State plan or under a waiver of 
     the plan.
       ``(D) Exceptions.--
       ``(i) Individuals eligible because of other aid or 
     assistance, elderly individuals, medically needy individuals, 
     and individuals eligible for medicare cost-sharing.--
     Subparagraphs (A), (B), and (C) shall not apply to the 
     determination of eligibility under the State plan or under a 
     waiver for medical assistance for the following:

       ``(I) Individuals who are eligible for medical assistance 
     under the State plan or under a waiver of the plan on a basis 
     that does not require a determination of income by the State 
     agency administering the State plan or waiver, including as a 
     result of eligibility for, or receipt of, other Federal or 
     State aid or assistance, individuals who are eligible on the 
     basis of receiving (or being treated as if receiving) 
     supplemental security income benefits under title XVI, and 
     individuals who are eligible as a result of being or being 
     deemed to be a child in foster care under the responsibility 
     of the State.
       ``(II) Individuals who have attained age 65.
       ``(III) Individuals who qualify for medical assistance 
     under the State plan or under any waiver of such plan on the 
     basis of being blind or disabled (or being treated as being 
     blind or disabled) without regard to whether the individual 
     is eligible for supplemental security income benefits under 
     title XVI on the basis of being blind or disabled and 
     including an individual who is eligible for medical 
     assistance on the basis of section 1902(e)(3).

[[Page 4247]]

       ``(IV) Individuals described in subsection (a)(10)(C).
       ``(V) Individuals described in any clause of subsection 
     (a)(10)(E).

       ``(ii) Express lane agency findings.--In the case of a 
     State that elects the Express Lane option under paragraph 
     (13), notwithstanding subparagraphs (A), (B), and (C), the 
     State may rely on a finding made by an Express Lane agency in 
     accordance with that paragraph relating to the income of an 
     individual for purposes of determining the individual's 
     eligibility for medical assistance under the State plan or 
     under a waiver of the plan.
       ``(iii) Medicare prescription drug subsidies 
     determinations.--Subparagraphs (A), (B), and (C) shall not 
     apply to any determinations of eligibility for premium and 
     cost-sharing subsidies under and in accordance with section 
     1860D-14 made by the State pursuant to section 1935(a)(2).
       ``(iv) Long-term care.--Subparagraphs (A), (B), and (C) 
     shall not apply to any determinations of eligibility of 
     individuals for purposes of medical assistance for nursing 
     facility services, a level of care in any institution 
     equivalent to that of nursing facility services, home or 
     community-based services furnished under a waiver or State 
     plan amendment under section 1915 or a waiver under section 
     1115, and services described in section 1917(c)(1)(C)(ii).
       ``(v) Grandfather of current enrollees until date of next 
     regular redetermination.--An individual who, on January 1, 
     2014, is enrolled in the State plan or under a waiver of the 
     plan and who would be determined ineligible for medical 
     assistance solely because of the application of the modified 
     gross income or household income standard described in 
     subparagraph (A), shall remain eligible for medical 
     assistance under the State plan or waiver (and subject to the 
     same premiums and cost-sharing as applied to the individual 
     on that date) through March 31, 2014, or the date on which 
     the individual's next regularly scheduled redetermination of 
     eligibility is to occur, whichever is later.
       ``(E) Transition planning and oversight.--Each State shall 
     submit to the Secretary for the Secretary's approval the 
     income eligibility thresholds proposed to be established 
     using modified gross income and household income, the 
     methodologies and procedures to be used to determine income 
     eligibility using modified gross income and household income 
     and, if applicable, a State plan amendment establishing an 
     optional eligibility category under subsection 
     (a)(10)(A)(ii)(XX). To the extent practicable, the State 
     shall use the same methodologies and procedures for purposes 
     of making such determinations as the State used on the date 
     of enactment of the Patient Protection and Affordable Care 
     Act. The Secretary shall ensure that the income eligibility 
     thresholds proposed to be established using modified gross 
     income and household income, including under the eligibility 
     category established under subsection (a)(10)(A)(ii)(XX), and 
     the methodologies and procedures proposed to be used to 
     determine income eligibility, will not result in children who 
     would have been eligible for medical assistance under the 
     State plan or under a waiver of the plan on the date of 
     enactment of the Patient Protection and Affordable Care Act 
     no longer being eligible for such assistance.
       ``(F) Limitation on secretarial authority.--The Secretary 
     shall not waive compliance with the requirements of this 
     paragraph except to the extent necessary to permit a State to 
     coordinate eligibility requirements for dual eligible 
     individuals (as defined in section 1915(h)(2)(B)) under the 
     State plan or under a waiver of the plan and under title 
     XVIII and individuals who require the level of care provided 
     in a hospital, a nursing facility, or an intermediate care 
     facility for the mentally retarded.
       ``(G) Definitions of modified gross income and household 
     income.--In this paragraph, the terms `modified gross income' 
     and `household income' have the meanings given such terms in 
     section 36B(d)(2) of the Internal Revenue Code of 1986.
       ``(H) Continued application of medicaid rules regarding 
     point-in-time income and sources of income.--The requirement 
     under this paragraph for States to use modified gross income 
     and household income to determine income eligibility for 
     medical assistance under the State plan or under any waiver 
     of such plan and for any other purpose applicable under the 
     plan or waiver for which a determination of income is 
     required shall not be construed as affecting or limiting the 
     application of--
       ``(i) the requirement under this title and under the State 
     plan or a waiver of the plan to determine an individual's 
     income as of the point in time at which an application for 
     medical assistance under the State plan or a waiver of the 
     plan is processed; or
       ``(ii) any rules established under this title or under the 
     State plan or a waiver of the plan regarding sources of 
     countable income.''.
       (b) Conforming Amendment.--Section 1902(a)(17) of such Act 
     (42 U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),'' 
     before ``(l)(3)''.
       (c) Effective Date.--The amendments made by subsections (a) 
     and (b) take effect on January 1, 2014.

     SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR 
                   EMPLOYER-SPONSORED INSURANCE.

       (a) In General.--Section 1906A of such Act (42 U.S.C. 
     1396e-1) is amended--
       (1) in subsection (a)--
       (A) by striking ``may elect to'' and inserting ``shall'';
       (B) by striking ``under age 19''; and
       (C) by inserting ``, in the case of an individual under age 
     19,'' after ``(and'';
       (2) in subsection (c), in the first sentence, by striking 
     ``under age 19''; and
       (3) in subsection (d)--
       (A) in paragraph (2)--
       (i) in the first sentence, by striking ``under age 19''; 
     and
       (ii) by striking the third sentence and inserting ``A State 
     may not require, as a condition of an individual (or the 
     individual's parent) being or remaining eligible for medical 
     assistance under this title, that the individual (or the 
     individual's parent) apply for enrollment in qualified 
     employer-sponsored coverage under this section.''; and
       (B) in paragraph (3), by striking ``the parent of an 
     individual under age 19'' and inserting ``an individual (or 
     the parent of an individual)''; and
       (4) in subsection (e), by striking ``under age 19'' each 
     place it appears.
       (b) Conforming Amendment.--The heading for section 1906A of 
     such Act (42 U.S.C. 1396e-1) is amended by striking ``option 
     for children''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2014.

     SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.

       (a) In General.--Section 1902(a)(10)(A)(i) of the Social 
     Security Act (42 U.S.C. 1396a), as amended by section 
     2001(a)(1), is amended--
       (1) by striking ``or'' at the end of subclause (VII);
       (2) by adding ``or'' at the end of subclause (VIII); and
       (3) by inserting after subclause (VIII) the following:

       ``(IX) who were in foster care under the responsibility of 
     a State for more than 6 months (whether or not consecutive) 
     but are no longer in such care, who are not described in any 
     of subclauses (I) through (VII) of this clause, and who are 
     under 25 years of age;''.

       (b) Option To Provide Presumptive Eligibility.--Section 
     1920(e) of such Act (42 U.S.C. 1396r-1(e)), as added by 
     section 2001(a)(4)(B) and amended by section 2001(e)(2)(C), 
     is amended by inserting ``, clause (i)(IX),'' after ``clause 
     (i)(VIII)''.
       (c) Conforming Amendments.--
       (1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), 
     as amended by section 2001(a)(5)(D), is amended by inserting 
     ``1902(a)(10)(A)(i)(IX),'' after 
     ``1902(a)(10)(A)(i)(VIII),''.
       (2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. 
     1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the 
     individual qualifies for medical assistance on the basis of 
     section 1902(a)(10)(A)(i)(IX)'' before the period.
       (d) Effective Date.--The amendments made by this section 
     take effect on January 1, 2019.

     SEC. 2005. PAYMENTS TO TERRITORIES.

       (a) Increase in Limit on Payments.--Section 1108(g) of the 
     Social Security Act (42 U.S.C. 1308(g)) is amended--
       (1) in paragraph (2), in the matter preceding subparagraph 
     (A), by striking ``paragraph (3)'' and inserting ``paragraphs 
     (3) and (5)'';
       (2) in paragraph (4), by striking ``and (3)'' and inserting 
     ``(3), and (4)''; and
       (3) by adding at the end the following paragraph:
       ``(5) Fiscal year 2011 and thereafter.--The amounts 
     otherwise determined under this subsection for Puerto Rico, 
     the Virgin Islands, Guam, the Northern Mariana Islands, and 
     American Samoa for the second, third, and fourth quarters of 
     fiscal year 2011, and for each fiscal year after fiscal year 
     2011 (after the application of subsection (f) and the 
     preceding paragraphs of this subsection), shall be increased 
     by 30 percent.''.
       (b) Disregard of Payments for Mandatory Expanded 
     Enrollment.--Section 1108(g)(4) of such Act (42 U.S.C. 
     1308(g)(4)) is amended--
       (1) by striking ``to fiscal years beginning'' and inserting 
     ``to--
       ``(A) fiscal years beginning'';
       (2) by striking the period at the end and inserting ``; 
     and''; and
       (3) by adding at the end the following:
       ``(B) fiscal years beginning with fiscal year 2014, 
     payments made to Puerto Rico, the Virgin Islands, Guam, the 
     Northern Mariana Islands, or American Samoa with respect to 
     amounts expended for medical assistance for newly eligible 
     (as defined in section 1905(y)(2)) nonpregnant childless 
     adults who are eligible under subclause (VIII) of section 
     1902(a)(10)(A)(i) and whose income (as determined under 
     section 1902(e)(14)) does not exceed (in the case of each 
     such commonwealth and territory respectively) the income 
     eligibility level in effect for that population under title 
     XIX or under a waiver on the date of enactment of the Patient 
     Protection and Affordable Care Act, shall not be taken into 
     account in applying subsection (f) (as increased in 
     accordance with paragraphs (1), (2), (3), and (5) of this 
     subsection) to such commonwealth or territory for such fiscal 
     year.''.
       (c) Increased FMAP.--
       (1) In general.--The first sentence of section 1905(b) of 
     the Social Security Act (42 U.S.C. 1396d(b)) is amended by 
     striking ``shall be 50 per centum'' and inserting ``shall be 
     55 percent''.
       (2) Effective date.--The amendment made by paragraph (1) 
     takes effect on January 1, 2011.

[[Page 4248]]



     SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR 
                   CERTAIN STATES RECOVERING FROM A MAJOR 
                   DISASTER.

       Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
     as amended by sections 2001(a)(3) and 2001(b)(2), is 
     amended--
       (1) in subsection (b), in the first sentence, by striking 
     ``subsection (y)'' and inserting ``subsections (y) and 
     (aa)''; and
       (2) by adding at the end the following new subsection:
       ``(aa)(1) Notwithstanding subsection (b), beginning January 
     1, 2011, the Federal medical assistance percentage for a 
     fiscal year for a disaster-recovery FMAP adjustment State 
     shall be equal to the following:
       ``(A) In the case of the first fiscal year (or part of a 
     fiscal year) for which this subsection applies to the State, 
     the Federal medical assistance percentage determined for the 
     fiscal year without regard to this subsection and subsection 
     (y), increased by 50 percent of the number of percentage 
     points by which the Federal medical assistance percentage 
     determined for the State for the fiscal year without regard 
     to this subsection and subsection (y), is less than the 
     Federal medical assistance percentage determined for the 
     State for the preceding fiscal year after the application of 
     only subsection (a) of section 5001 of Public Law 111-5 (if 
     applicable to the preceding fiscal year) and without regard 
     to this subsection, subsection (y), and subsections (b) and 
     (c) of section 5001 of Public Law 111-5.
       ``(B) In the case of the second or any succeeding fiscal 
     year for which this subsection applies to the State, the 
     Federal medical assistance percentage determined for the 
     preceding fiscal year under this subsection for the State, 
     increased by 25 percent of the number of percentage points by 
     which the Federal medical assistance percentage determined 
     for the State for the fiscal year without regard to this 
     subsection and subsection (y), is less than the Federal 
     medical assistance percentage determined for the State for 
     the preceding fiscal year under this subsection.
       ``(2) In this subsection, the term `disaster-recovery FMAP 
     adjustment State' means a State that is one of the 50 States 
     or the District of Columbia, for which, at any time during 
     the preceding 7 fiscal years, the President has declared a 
     major disaster under section 401 of the Robert T. Stafford 
     Disaster Relief and Emergency Assistance Act and determined 
     as a result of such disaster that every county or parish in 
     the State warrant individual and public assistance or public 
     assistance from the Federal Government under such Act and for 
     which--
       ``(A) in the case of the first fiscal year (or part of a 
     fiscal year) for which this subsection applies to the State, 
     the Federal medical assistance percentage determined for the 
     State for the fiscal year without regard to this subsection 
     and subsection (y), is less than the Federal medical 
     assistance percentage determined for the State for the 
     preceding fiscal year after the application of only 
     subsection (a) of section 5001 of Public Law 111-5 (if 
     applicable to the preceding fiscal year) and without regard 
     to this subsection, subsection (y), and subsections (b) and 
     (c) of section 5001 of Public Law 111-5, by at least 3 
     percentage points; and
       ``(B) in the case of the second or any succeeding fiscal 
     year for which this subsection applies to the State, the 
     Federal medical assistance percentage determined for the 
     State for the fiscal year without regard to this subsection 
     and subsection (y), is less than the Federal medical 
     assistance percentage determined for the State for the 
     preceding fiscal year under this subsection by at least 3 
     percentage points.
       ``(3) The Federal medical assistance percentage determined 
     for a disaster-recovery FMAP adjustment State under paragraph 
     (1) shall apply for purposes of this title (other than with 
     respect to disproportionate share hospital payments described 
     in section 1923 and payments under this title that are based 
     on the enhanced FMAP described in 2105(b)) and shall not 
     apply with respect to payments under title IV (other than 
     under part E of title IV) or payments under title XXI.''.

     SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.

       (a) Rescission.--Any amounts available to the Medicaid 
     Improvement Fund established under section 1941 of the Social 
     Security Act (42 U.S.C. 1396w-1) for any of fiscal years 2014 
     through 2018 that are available for expenditure from the Fund 
     and that are not so obligated as of the date of the enactment 
     of this Act are rescinded.
       (b) Conforming Amendments.--Section 1941(b)(1) of the 
     Social Security Act (42 U.S.C. 1396w-1(b)(1)) is amended--
       (1) in subparagraph (A), by striking ``$100,000,000'' and 
     inserting ``$0''; and
       (2) in subparagraph (B), by striking ``$150,000,000'' and 
     inserting ``$0''.

   Subtitle B--Enhanced Support for the Children's Health Insurance 
                                Program

     SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR 
                   CHIP.

       (a) In General.--Section 2105(b) of the Social Security Act 
     (42 U.S.C. 1397ee(b)) is amended by adding at the end the 
     following: ``Notwithstanding the preceding sentence, during 
     the period that begins on October 1, 2013, and ends on 
     September 30, 2019, the enhanced FMAP determined for a State 
     for a fiscal year (or for any portion of a fiscal year 
     occurring during such period) shall be increased by 23 
     percentage points, but in no case shall exceed 100 percent. 
     The increase in the enhanced FMAP under the preceding 
     sentence shall not apply with respect to determining the 
     payment to a State under subsection (a)(1) for expenditures 
     described in subparagraph (D)(iv), paragraphs (8), (9), (11) 
     of subsection (c), or clause (4) of the first sentence of 
     section 1905(b).''.
       (b) Maintenance of Effort.--
       (1) In general.--Section 2105(d) of the Social Security Act 
     (42 U.S.C. 1397ee(d)) is amended by adding at the end the 
     following:
       ``(3) Continuation of eligibility standards for children 
     until october 1, 2019.--
       ``(A) In general.--During the period that begins on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act and ends on September 30, 2019, a State shall not 
     have in effect eligibility standards, methodologies, or 
     procedures under its State child health plan (including any 
     waiver under such plan) for children (including children 
     provided medical assistance for which payment is made under 
     section 2105(a)(1)(A)) that are more restrictive than the 
     eligibility standards, methodologies, or procedures, 
     respectively, under such plan (or waiver) as in effect on the 
     date of enactment of that Act. The preceding sentence shall 
     not be construed as preventing a State during such period 
     from--
       ``(i) applying eligibility standards, methodologies, or 
     procedures for children under the State child health plan or 
     under any waiver of the plan that are less restrictive than 
     the eligibility standards, methodologies, or procedures, 
     respectively, for children under the plan or waiver that are 
     in effect on the date of enactment of such Act; or
       ``(ii) imposing a limitation described in section 
     2112(b)(7) for a fiscal year in order to limit expenditures 
     under the State child health plan to those for which Federal 
     financial participation is available under this section for 
     the fiscal year.
       ``(B) Assurance of exchange coverage for targeted low-
     income children unable to be provided child health assistance 
     as a result of funding shortfalls.--In the event that 
     allotments provided under section 2104 are insufficient to 
     provide coverage to all children who are eligible to be 
     targeted low-income children under the State child health 
     plan under this title, a State shall establish procedures to 
     ensure that such children are provided coverage through an 
     Exchange established by the State under section 1311 of the 
     Patient Protection and Affordable Care Act.''.
       (2) Conforming amendment to title xxi medicaid maintenance 
     of effort.--Section 2105(d)(1) of the Social Security Act (42 
     U.S.C. 1397ee(d)(1)) is amended by adding before the period 
     ``, except as required under section 1902(e)(14)''.
       (c) No Enrollment Bonus Payments for Children Enrolled 
     After Fiscal Year 2013.--Section 2105(a)(3)(F)(iii) of the 
     Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is 
     amended by inserting ``or any children enrolled on or after 
     October 1, 2013'' before the period.
       (d) Income Eligibility Determined Using Modified Gross 
     Income.--
       (1) State plan requirement.--Section 2102(b)(1)(B) of the 
     Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
       (A) in clause (iii), by striking ``and'' after the 
     semicolon;
       (B) in clause (iv), by striking the period and inserting 
     ``; and''; and
       (C) by adding at the end the following:
       ``(v) shall, beginning January 1, 2014, use modified gross 
     income and household income (as defined in section 36B(d)(2) 
     of the Internal Revenue Code of 1986) to determine 
     eligibility for child health assistance under the State child 
     health plan or under any waiver of such plan and for any 
     other purpose applicable under the plan or waiver for which a 
     determination of income is required, including with respect 
     to the imposition of premiums and cost-sharing, consistent 
     with section 1902(e)(14).''.
       (2) Conforming amendment.--Section 2107(e)(1) of the Social 
     Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
       (A) by redesignating subparagraphs (E) through (L) as 
     subparagraphs (F) through (M), respectively; and
       (B) by inserting after subparagraph (D), the following:
       ``(E) Section 1902(e)(14) (relating to income determined 
     using modified gross income and household income).''.
       (e) Application of Streamlined Enrollment System.--Section 
     2107(e)(1) of the Social Security Act (42 U.S.C. 
     1397gg(e)(1)), as amended by subsection (d)(2), is amended by 
     adding at the end the following:
       ``(N) Section 1943(b) (relating to coordination with State 
     Exchanges and the State Medicaid agency).''.
       (f) CHIP Eligibility for Children Ineligible for Medicaid 
     as a Result of Elimination of Disregards.--Notwithstanding 
     any other provision of law, a State shall treat any child who 
     is determined to be ineligible for medical assistance under 
     the State Medicaid plan or under a waiver of the plan as a 
     result of the elimination of the application of an income 
     disregard based on expense or type of income, as required 
     under section 1902(e)(14) of the Social Security Act (as 
     added by this Act), as a targeted low-income child under 
     section 2110(b) (unless the child is excluded under paragraph 
     (2) of that section) and shall provide child health 
     assistance to the child under the State child health plan 
     (whether implemented under title XIX or XXI, or both, of the 
     Social Security Act).

     SEC. 2102. TECHNICAL CORRECTIONS.

       (a) CHIPRA.--Effective as if included in the enactment of 
     the Children's Health Insurance

[[Page 4249]]

     Program Reauthorization Act of 2009 (Public Law 111-3) (in 
     this section referred to as ``CHIPRA''):
       (1) Section 2104(m) of the Social Security Act, as added by 
     section 102 of CHIPRA, is amended--
       (A) by redesignating paragraph (7) as paragraph (8); and
       (B) by inserting after paragraph (6), the following:
       ``(7) Adjustment of fiscal year 2010 allotments to account 
     for changes in projected spending for certain previously 
     approved expansion programs.--For purposes of recalculating 
     the fiscal year 2010 allotment, in the case of one of the 50 
     States or the District of Columbia that has an approved State 
     plan amendment effective January 1, 2006, to provide child 
     health assistance through the provision of benefits under the 
     State plan under title XIX for children from birth through 
     age 5 whose family income does not exceed 200 percent of the 
     poverty line, the Secretary shall increase the allotment by 
     an amount that would be equal to the Federal share of 
     expenditures that would have been claimed at the enhanced 
     FMAP rate rather than the Federal medical assistance 
     percentage matching rate for such population.''.
       (2) Section 605 of CHIPRA is amended by striking ``legal 
     residents'' and insert ``lawfully residing in the United 
     States''.
       (3) Subclauses (I) and (II) of paragraph (3)(C)(i) of 
     section 2105(a) of the Social Security Act (42 U.S.C. 
     1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are 
     each amended by striking ``, respectively''.
       (4) Section 2105(a)(3)(E)(ii) of the Social Security Act 
     (42 U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of 
     CHIPRA, is amended by striking subclause (IV).
       (5) Section 2105(c)(9)(B) of the Social Security Act (42 
     U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of 
     CHIPRA, is amended by striking ``section 1903(a)(3)(F)'' and 
     inserting ``section 1903(a)(3)(G)''.
       (6) Section 2109(b)(2)(B) of the Social Security Act (42 
     U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, 
     is amended by striking ``the child population growth factor 
     under section 2104(m)(5)(B)'' and inserting ``a high-
     performing State under section 2111(b)(3)(B)''.
       (7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 
     U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of 
     CHIPRA, is amended by striking ``school or school system'' 
     and inserting ``local educational agency (as defined under 
     section 9101 of the Elementary and Secondary Education Act of 
     1965''.
       (8) Section 211(a)(1)(B) of CHIPRA is amended--
       (A) by striking ``is amended'' and all that follows through 
     ``adding'' and inserting ``is amended by adding''; and
       (B) by redesignating the new subparagraph to be added by 
     such section to section 1903(a)(3) of the Social Security Act 
     as a new subparagraph (H).
       (b) ARRA.--Effective as if included in the enactment of 
     section 5006(a) of division B of the American Recovery and 
     Reinvestment Act of 2009 (Public Law 111-5), the second 
     sentence of section 1916A(a)(1) of the Social Security Act 
     (42 U.S.C. 1396o-1(a)(1)) is amended by striking ``or (i)'' 
     and inserting ``, (i), or (j)''.

        Subtitle C--Medicaid and CHIP Enrollment Simplification

     SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
                   STATE HEALTH INSURANCE EXCHANGES.

       Title XIX of the Social Security Act (42 U.S.C. 1397aa et 
     seq.) is amended by adding at the end the following:

     ``SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
                   STATE HEALTH INSURANCE EXCHANGES.

       ``(a) Condition for Participation in Medicaid.--As a 
     condition of the State plan under this title and receipt of 
     any Federal financial assistance under section 1903(a) for 
     calendar quarters beginning after January 1, 2014, a State 
     shall ensure that the requirements of subsection (b) is met.
       ``(b) Enrollment Simplification and Coordination With State 
     Health Insurance Exchanges and Chip.--
       ``(1) In general.--A State shall establish procedures for--
       ``(A) enabling individuals, through an Internet website 
     that meets the requirements of paragraph (4), to apply for 
     medical assistance under the State plan or under a waiver of 
     the plan, to be enrolled in the State plan or waiver, to 
     renew their enrollment in the plan or waiver, and to consent 
     to enrollment or reenrollment in the State plan through 
     electronic signature;
       ``(B) enrolling, without any further determination by the 
     State and through such website, individuals who are 
     identified by an Exchange established by the State under 
     section 1311 of the Patient Protection and Affordable Care 
     Act as being eligible for--
       ``(i) medical assistance under the State plan or under a 
     waiver of the plan; or
       ``(ii) child health assistance under the State child health 
     plan under title XXI;
       ``(C) ensuring that individuals who apply for but are 
     determined to be ineligible for medical assistance under the 
     State plan or a waiver or ineligible for child health 
     assistance under the State child health plan under title XXI, 
     are screened for eligibility for enrollment in qualified 
     health plans offered through such an Exchange and, if 
     applicable, premium assistance for the purchase of a 
     qualified health plan under section 36B of the Internal 
     Revenue Code of 1986 (and, if applicable, advance payment of 
     such assistance under section 1412 of the Patient Protection 
     and Affordable Care Act), and, if eligible, enrolled in such 
     a plan without having to submit an additional or separate 
     application, and that such individuals receive information 
     regarding reduced cost-sharing for eligible individuals under 
     section 1402 of the Patient Protection and Affordable Care 
     Act, and any other assistance or subsidies available for 
     coverage obtained through the Exchange;
       ``(D) ensuring that the State agency responsible for 
     administering the State plan under this title (in this 
     section referred to as the `State Medicaid agency'), the 
     State agency responsible for administering the State child 
     health plan under title XXI (in this section referred to as 
     the `State CHIP agency') and an Exchange established by the 
     State under section 1311 of the Patient Protection and 
     Affordable Care Act utilize a secure electronic interface 
     sufficient to allow for a determination of an individual's 
     eligibility for such medical assistance, child health 
     assistance, or premium assistance, and enrollment in the 
     State plan under this title, title XXI, or a qualified health 
     plan, as appropriate;
       ``(E) coordinating, for individuals who are enrolled in the 
     State plan or under a waiver of the plan and who are also 
     enrolled in a qualified health plan offered through such an 
     Exchange, and for individuals who are enrolled in the State 
     child health plan under title XXI and who are also enrolled 
     in a qualified health plan, the provision of medical 
     assistance or child health assistance to such individuals 
     with the coverage provided under the qualified health plan in 
     which they are enrolled, including services described in 
     section 1905(a)(4)(B) (relating to early and periodic 
     screening, diagnostic, and treatment services defined in 
     section 1905(r)) and provided in accordance with the 
     requirements of section 1902(a)(43); and
       ``(F) conducting outreach to and enrolling vulnerable and 
     underserved populations eligible for medical assistance under 
     this title XIX or for child health assistance under title 
     XXI, including children, unaccompanied homeless youth, 
     children and youth with special health care needs, pregnant 
     women, racial and ethnic minorities, rural populations, 
     victims of abuse or trauma, individuals with mental health or 
     substance-related disorders, and individuals with HIV/AIDS.
       ``(2) Agreements with state health insurance exchanges.--
     The State Medicaid agency and the State CHIP agency may enter 
     into an agreement with an Exchange established by the State 
     under section 1311 of the Patient Protection and Affordable 
     Care Act under which the State Medicaid agency or State CHIP 
     agency may determine whether a State resident is eligible for 
     premium assistance for the purchase of a qualified health 
     plan under section 36B of the Internal Revenue Code of 1986 
     (and, if applicable, advance payment of such assistance under 
     section 1412 of the Patient Protection and Affordable Care 
     Act), so long as the agreement meets such conditions and 
     requirements as the Secretary of the Treasury may prescribe 
     to reduce administrative costs and the likelihood of 
     eligibility errors and disruptions in coverage.
       ``(3) Streamlined enrollment system.--The State Medicaid 
     agency and State CHIP agency shall participate in and comply 
     with the requirements for the system established under 
     section 1413 of the Patient Protection and Affordable Care 
     Act (relating to streamlined procedures for enrollment 
     through an Exchange, Medicaid, and CHIP).
       ``(4) Enrollment website requirements.--The procedures 
     established by State under paragraph (1) shall include 
     establishing and having in operation, not later than January 
     1, 2014, an Internet website that is linked to any website of 
     an Exchange established by the State under section 1311 of 
     the Patient Protection and Affordable Care Act and to the 
     State CHIP agency (if different from the State Medicaid 
     agency) and allows an individual who is eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     and who is eligible to receive premium credit assistance for 
     the purchase of a qualified health plan under section 36B of 
     the Internal Revenue Code of 1986 to compare the benefits, 
     premiums, and cost-sharing applicable to the individual under 
     the State plan or waiver with the benefits, premiums, and 
     cost-sharing available to the individual under a qualified 
     health plan offered through such an Exchange, including, in 
     the case of a child, the coverage that would be provided for 
     the child through the State plan or waiver with the coverage 
     that would be provided to the child through enrollment in 
     family coverage under that plan and as supplemental coverage 
     by the State under the State plan or waiver.
       ``(5) Continued need for assessment for home and community-
     based services.--Nothing in paragraph (1) shall limit or 
     modify the requirement that the State assess an individual 
     for purposes of providing home and community-based services 
     under the State plan or under any waiver of such plan for 
     individuals described in subsection (a)(10)(A)(ii)(VI).''.

     SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE 
                   ELIGIBILITY DETERMINATIONS FOR ALL MEDICAID 
                   ELIGIBLE POPULATIONS.

       (a) In General.--Section 1902(a)(47) of the Social Security 
     Act (42 U.S.C. 1396a(a)(47)) is amended--
       (1) by striking ``at the option of the State, provide'' and 
     inserting ``provide--
       ``(A) at the option of the State,'';
       (2) by inserting ``and'' after the semicolon; and
       (3) by adding at the end the following:

[[Page 4250]]

       ``(B) that any hospital that is a participating provider 
     under the State plan may elect to be a qualified entity for 
     purposes of determining, on the basis of preliminary 
     information, whether any individual is eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     for purposes of providing the individual with medical 
     assistance during a presumptive eligibility period, in the 
     same manner, and subject to the same requirements, as apply 
     to the State options with respect to populations described in 
     section 1920, 1920A, or 1920B (but without regard to whether 
     the State has elected to provide for a presumptive 
     eligibility period under any such sections), subject to such 
     guidance as the Secretary shall establish;''.
       (b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such 
     Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended--
       (1) by striking ``or for'' and inserting ``for''; and
       (2) by inserting before the period at the end the 
     following: ``, or for medical assistance provided to an 
     individual during a presumptive eligibility period resulting 
     from a determination of presumptive eligibility made by a 
     hospital that elects under section 1902(a)(47)(B) to be a 
     qualified entity for such purpose''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2014, and apply to services 
     furnished on or after that date.

             Subtitle D--Improvements to Medicaid Services

     SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d), is amended--
       (1) in subsection (a)--
       (A) in paragraph (27), by striking ``and'' at the end;
       (B) by redesignating paragraph (28) as paragraph (29); and
       (C) by inserting after paragraph (27) the following new 
     paragraph:
       ``(28) freestanding birth center services (as defined in 
     subsection (l)(3)(A)) and other ambulatory services that are 
     offered by a freestanding birth center (as defined in 
     subsection (l)(3)(B)) and that are otherwise included in the 
     plan; and''; and
       (2) in subsection (l), by adding at the end the following 
     new paragraph:
       ``(3)(A) The term `freestanding birth center services' 
     means services furnished to an individual at a freestanding 
     birth center (as defined in subparagraph (B)) at such center.
       ``(B) The term `freestanding birth center' means a health 
     facility--
       ``(i) that is not a hospital;
       ``(ii) where childbirth is planned to occur away from the 
     pregnant woman's residence;
       ``(iii) that is licensed or otherwise approved by the State 
     to provide prenatal labor and delivery or postpartum care and 
     other ambulatory services that are included in the plan; and
       ``(iv) that complies with such other requirements relating 
     to the health and safety of individuals furnished services by 
     the facility as the State shall establish.
       ``(C) A State shall provide separate payments to providers 
     administering prenatal labor and delivery or postpartum care 
     in a freestanding birth center (as defined in subparagraph 
     (B)), such as nurse midwives and other providers of services 
     such as birth attendants recognized under State law, as 
     determined appropriate by the Secretary. For purposes of the 
     preceding sentence, the term `birth attendant' means an 
     individual who is recognized or registered by the State 
     involved to provide health care at childbirth and who 
     provides such care within the scope of practice under which 
     the individual is legally authorized to perform such care 
     under State law (or the State regulatory mechanism provided 
     by State law), regardless of whether the individual is under 
     the supervision of, or associated with, a physician or other 
     health care provider. Nothing in this subparagraph shall be 
     construed as changing State law requirements applicable to a 
     birth attendant.''.
       (b) Conforming Amendment.--Section 1902(a)(10)(A) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended 
     in the matter preceding clause (i) by striking ``and (21)'' 
     and inserting ``, (21), and (28)''.
       (c) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by this section shall take effect on the date 
     of the enactment of this Act and shall apply to services 
     furnished on or after such date.
       (2) Exception if state legislation required.--In the case 
     of a State plan for medical assistance under title XIX of the 
     Social Security Act which the Secretary of Health and Human 
     Services determines requires State legislation (other than 
     legislation appropriating funds) in order for the plan to 
     meet the additional requirement imposed by the amendments 
     made by this section, the State plan shall not be regarded as 
     failing to comply with the requirements of such title solely 
     on the basis of its failure to meet this additional 
     requirement before the first day of the first calendar 
     quarter beginning after the close of the first regular 
     session of the State legislature that begins after the date 
     of the enactment of this Act. For purposes of the previous 
     sentence, in the case of a State that has a 2-year 
     legislative session, each year of such session shall be 
     deemed to be a separate regular session of the State 
     legislature.

     SEC. 2302. CONCURRENT CARE FOR CHILDREN.

       (a) In General.--Section 1905(o)(1) of the Social Security 
     Act (42 U.S.C. 1396d(o)(1)) is amended--
       (1) in subparagraph (A), by striking ``subparagraph (B)'' 
     and inserting ``subparagraphs (B) and (C)''; and
       (2) by adding at the end the following new subparagraph:
       ``(C) A voluntary election to have payment made for hospice 
     care for a child (as defined by the State) shall not 
     constitute a waiver of any rights of the child to be provided 
     with, or to have payment made under this title for, services 
     that are related to the treatment of the child's condition 
     for which a diagnosis of terminal illness has been made.''.
       (b) Application to CHIP.--Section 2110(a)(23) of the Social 
     Security Act (42 U.S.C. 1397jj(a)(23)) is amended by 
     inserting ``(concurrent, in the case of an individual who is 
     a child, with care related to the treatment of the child's 
     condition with respect to which a diagnosis of terminal 
     illness has been made'' after ``hospice care''.

     SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING 
                   SERVICES.

       (a) Coverage as Optional Categorically Needy Group.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
     section 2001(e), is amended--
       (A) in subclause (XIX), by striking ``or'' at the end;
       (B) in subclause (XX), by adding ``or'' at the end; and
       (C) by adding at the end the following new subclause:

       ``(XXI) who are described in subsection (ii) (relating to 
     individuals who meet certain income standards);''.

       (2) Group described.--Section 1902 of such Act (42 U.S.C. 
     1396a), as amended by section 2001(d), is amended by adding 
     at the end the following new subsection:
       ``(ii)(1) Individuals described in this subsection are 
     individuals--
       ``(A) whose income does not exceed an income eligibility 
     level established by the State that does not exceed the 
     highest income eligibility level established under the State 
     plan under this title (or under its State child health plan 
     under title XXI) for pregnant women; and
       ``(B) who are not pregnant.
       ``(2) At the option of a State, individuals described in 
     this subsection may include individuals who, had individuals 
     applied on or before January 1, 2007, would have been made 
     eligible pursuant to the standards and processes imposed by 
     that State for benefits described in clause (XV) of the 
     matter following subparagraph (G) of section subsection 
     (a)(10) pursuant to a waiver granted under section 1115.
       ``(3) At the option of a State, for purposes of subsection 
     (a)(17)(B), in determining eligibility for services under 
     this subsection, the State may consider only the income of 
     the applicant or recipient.''.
       (3) Limitation on benefits.--Section 1902(a)(10) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by 
     section 2001(a)(5)(A), is amended in the matter following 
     subparagraph (G)--
       (A) by striking ``and (XV)'' and inserting ``(XV)''; and
       (B) by inserting ``, and (XVI) the medical assistance made 
     available to an individual described in subsection (ii) shall 
     be limited to family planning services and supplies described 
     in section 1905(a)(4)(C) including medical diagnosis and 
     treatment services that are provided pursuant to a family 
     planning service in a family planning setting'' before the 
     semicolon.
       (4) Conforming amendments.--
       (A) Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)), as amended by section 2001(e)(2)(A), is amended in 
     the matter preceding paragraph (1)--
       (i) in clause (xiv), by striking ``or'' at the end;
       (ii) in clause (xv), by adding ``or'' at the end; and
       (iii) by inserting after clause (xv) the following:
       ``(xvi) individuals described in section 1902(ii),''.
       (B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), 
     as amended by section 2001(e)(2)(B), is amended by inserting 
     ``1902(a)(10)(A)(ii)(XXI),'' after 
     ``1902(a)(10)(A)(ii)(XX),''.
       (b) Presumptive Eligibility.--
       (1) In general.--Title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.) is amended by inserting after section 
     1920B the following:


         ``presumptive eligibility for family planning services

       ``Sec. 1920C.  (a) State Option.--State plan approved under 
     section 1902 may provide for making medical assistance 
     available to an individual described in section 1902(ii) 
     (relating to individuals who meet certain income eligibility 
     standard) during a presumptive eligibility period. In the 
     case of an individual described in section 1902(ii), such 
     medical assistance shall be limited to family planning 
     services and supplies described in 1905(a)(4)(C) and, at the 
     State's option, medical diagnosis and treatment services that 
     are provided in conjunction with a family planning service in 
     a family planning setting.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Presumptive eligibility period.--The term 
     `presumptive eligibility period' means, with respect to an 
     individual described in subsection (a), the period that--
       ``(A) begins with the date on which a qualified entity 
     determines, on the basis of preliminary information, that the 
     individual is described in section 1902(ii); and

[[Page 4251]]

       ``(B) ends with (and includes) the earlier of--
       ``(i) the day on which a determination is made with respect 
     to the eligibility of such individual for services under the 
     State plan; or
       ``(ii) in the case of such an individual who does not file 
     an application by the last day of the month following the 
     month during which the entity makes the determination 
     referred to in subparagraph (A), such last day.
       ``(2) Qualified entity.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `qualified entity' means any entity that--
       ``(i) is eligible for payments under a State plan approved 
     under this title; and
       ``(ii) is determined by the State agency to be capable of 
     making determinations of the type described in paragraph 
     (1)(A).
       ``(B) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a State from limiting the 
     classes of entities that may become qualified entities in 
     order to prevent fraud and abuse.
       ``(c) Administration.--
       ``(1) In general.--The State agency shall provide qualified 
     entities with--
       ``(A) such forms as are necessary for an application to be 
     made by an individual described in subsection (a) for medical 
     assistance under the State plan; and
       ``(B) information on how to assist such individuals in 
     completing and filing such forms.
       ``(2) Notification requirements.--A qualified entity that 
     determines under subsection (b)(1)(A) that an individual 
     described in subsection (a) is presumptively eligible for 
     medical assistance under a State plan shall--
       ``(A) notify the State agency of the determination within 5 
     working days after the date on which determination is made; 
     and
       ``(B) inform such individual at the time the determination 
     is made that an application for medical assistance is 
     required to be made by not later than the last day of the 
     month following the month during which the determination is 
     made.
       ``(3) Application for medical assistance.--In the case of 
     an individual described in subsection (a) who is determined 
     by a qualified entity to be presumptively eligible for 
     medical assistance under a State plan, the individual shall 
     apply for medical assistance by not later than the last day 
     of the month following the month during which the 
     determination is made.
       ``(d) Payment.--Notwithstanding any other provision of law, 
     medical assistance that--
       ``(1) is furnished to an individual described in subsection 
     (a)--
       ``(A) during a presumptive eligibility period; and
       ``(B) by a entity that is eligible for payments under the 
     State plan; and
       ``(2) is included in the care and services covered by the 
     State plan,

     shall be treated as medical assistance provided by such plan 
     for purposes of clause (4) of the first sentence of section 
     1905(b).''.
       (2) Conforming amendments.--
       (A) Section 1902(a)(47) of the Social Security Act (42 
     U.S.C. 1396a(a)(47)), as amended by section 2202(a), is 
     amended--
       (i) in subparagraph (A), by inserting before the semicolon 
     at the end the following: ``and provide for making medical 
     assistance available to individuals described in subsection 
     (a) of section 1920C during a presumptive eligibility period 
     in accordance with such section''; and
       (ii) in subparagraph (B), by striking ``or 1920B'' and 
     inserting ``1920B, or 1920C''.
       (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
     1396b(u)(1)(D)(v)), as amended by section 2202(b), is amended 
     by inserting ``or for medical assistance provided to an 
     individual described in subsection (a) of section 1920C 
     during a presumptive eligibility period under such section,'' 
     after ``1920B during a presumptive eligibility period under 
     such section,''.
       (c) Clarification of Coverage of Family Planning Services 
     and Supplies.--Section 1937(b) of the Social Security Act (42 
     U.S.C. 1396u-7(b)), as amended by section 2001(c), is amended 
     by adding at the end the following:
       ``(7) Coverage of family planning services and supplies.--
     Notwithstanding the previous provisions of this section, a 
     State may not provide for medical assistance through 
     enrollment of an individual with benchmark coverage or 
     benchmark-equivalent coverage under this section unless such 
     coverage includes for any individual described in section 
     1905(a)(4)(C), medical assistance for family planning 
     services and supplies in accordance with such section.''.
       (d) Effective Date.--The amendments made by this section 
     take effect on the date of the enactment of this Act and 
     shall apply to items and services furnished on or after such 
     date.

     SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE.

       Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)) is amended by inserting ``or the care and services 
     themselves, or both'' before ``(if provided in or after''.

 Subtitle E--New Options for States to Provide Long-Term Services and 
                                Supports

     SEC. 2401. COMMUNITY FIRST CHOICE OPTION.

       Section 1915 of the Social Security Act (42 U.S.C. 1396n) 
     is amended by adding at the end the following:
       ``(k) State Plan Option To Provide Home and Community-based 
     Attendant Services and Supports.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, beginning October 1, 2010, a State may 
     provide through a State plan amendment for the provision of 
     medical assistance for home and community-based attendant 
     services and supports for individuals who are eligible for 
     medical assistance under the State plan whose income does not 
     exceed 150 percent of the poverty line (as defined in section 
     2110(c)(5)) or, if greater, the income level applicable for 
     an individual who has been determined to require an 
     institutional level of care to be eligible for nursing 
     facility services under the State plan and with respect to 
     whom there has been a determination that, but for the 
     provision of such services, the individuals would require the 
     level of care provided in a hospital, a nursing facility, an 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases, the cost of which could be 
     reimbursed under the State plan, but only if the individual 
     chooses to receive such home and community-based attendant 
     services and supports, and only if the State meets the 
     following requirements:
       ``(A) Availability.--The State shall make available home 
     and community-based attendant services and supports to 
     eligible individuals, as needed, to assist in accomplishing 
     activities of daily living, instrumental activities of daily 
     living, and health-related tasks through hands-on assistance, 
     supervision, or cueing--
       ``(i) under a person-centered plan of services and supports 
     that is based on an assessment of functional need and that is 
     agreed to in writing by the individual or, as appropriate, 
     the individual's representative;
       ``(ii) in a home or community setting, which does not 
     include a nursing facility, institution for mental diseases, 
     or an intermediate care facility for the mentally retarded;
       ``(iii) under an agency-provider model or other model (as 
     defined in paragraph (6)(C )); and
       ``(iv) the furnishing of which--

       ``(I) is selected, managed, and dismissed by the 
     individual, or, as appropriate, with assistance from the 
     individual's representative;
       ``(II) is controlled, to the maximum extent possible, by 
     the individual or where appropriate, the individual's 
     representative, regardless of who may act as the employer of 
     record; and
       ``(III) provided by an individual who is qualified to 
     provide such services, including family members (as defined 
     by the Secretary).

       ``(B) Included services and supports.--In addition to 
     assistance in accomplishing activities of daily living, 
     instrumental activities of daily living, and health related 
     tasks, the home and community-based attendant services and 
     supports made available include--
       ``(i) the acquisition, maintenance, and enhancement of 
     skills necessary for the individual to accomplish activities 
     of daily living, instrumental activities of daily living, and 
     health related tasks;
       ``(ii) back-up systems or mechanisms (such as the use of 
     beepers or other electronic devices) to ensure continuity of 
     services and supports; and
       ``(iii) voluntary training on how to select, manage, and 
     dismiss attendants.
       ``(C) Excluded services and supports.--Subject to 
     subparagraph (D), the home and community-based attendant 
     services and supports made available do not include--
       ``(i) room and board costs for the individual;
       ``(ii) special education and related services provided 
     under the Individuals with Disabilities Education Act and 
     vocational rehabilitation services provided under the 
     Rehabilitation Act of 1973;
       ``(iii) assistive technology devices and assistive 
     technology services other than those under (1)(B)(ii);
       ``(iv) medical supplies and equipment; or
       ``(v) home modifications.
       ``(D) Permissible services and supports.--The home and 
     community-based attendant services and supports may include--
       ``(i) expenditures for transition costs such as rent and 
     utility deposits, first month's rent and utilities, bedding, 
     basic kitchen supplies, and other necessities required for an 
     individual to make the transition from a nursing facility, 
     institution for mental diseases, or intermediate care 
     facility for the mentally retarded to a community-based home 
     setting where the individual resides; and
       ``(ii) expenditures relating to a need identified in an 
     individual's person-centered plan of services that increase 
     independence or substitute for human assistance, to the 
     extent that expenditures would otherwise be made for the 
     human assistance.
       ``(2) Increased federal financial participation.--For 
     purposes of payments to a State under section 1903(a)(1), 
     with respect to amounts expended by the State to provide 
     medical assistance under the State plan for home and 
     community-based attendant services and supports to eligible 
     individuals in accordance with this subsection during a 
     fiscal year quarter occurring during the period described in 
     paragraph (1), the Federal medical assistance percentage 
     applicable to the State (as determined under section 1905(b)) 
     shall be increased by 6 percentage points.
       ``(3) State requirements.--In order for a State plan 
     amendment to be approved under this subsection, the State 
     shall--
       ``(A) develop and implement such amendment in collaboration 
     with a Development and Implementation Council established by 
     the State that includes a majority of members with 
     disabilities, elderly individuals, and their representatives 
     and consults and collaborates with such individuals;
       ``(B) provide consumer controlled home and community-based 
     attendant services and supports to individuals on a statewide 
     basis, in a manner that provides such services and supports 
     in the most integrated setting appropriate to the 
     individual's needs, and without regard to the individual's 
     age, type or nature of disability, severity of disability, or 
     the form of home and

[[Page 4252]]

     community-based attendant services and supports that the 
     individual requires in order to lead an independent life;
       ``(C) with respect to expenditures during the first full 
     fiscal year in which the State plan amendment is implemented, 
     maintain or exceed the level of State expenditures for 
     medical assistance that is provided under section 1905(a), 
     section 1915, section 1115, or otherwise to individuals with 
     disabilities or elderly individuals attributable to the 
     preceding fiscal year;
       ``(D) establish and maintain a comprehensive, continuous 
     quality assurance system with respect to community- based 
     attendant services and supports that--
       ``(i) includes standards for agency-based and other 
     delivery models with respect to training, appeals for denials 
     and reconsideration procedures of an individual plan, and 
     other factors as determined by the Secretary;
       ``(ii) incorporates feedback from consumers and their 
     representatives, disability organizations, providers, 
     families of disabled or elderly individuals, members of the 
     community, and others and maximizes consumer independence and 
     consumer control;
       ``(iii) monitors the health and well-being of each 
     individual who receives home and community-based attendant 
     services and supports, including a process for the mandatory 
     reporting, investigation, and resolution of allegations of 
     neglect, abuse, or exploitation in connection with the 
     provision of such services and supports; and
       ``(iv) provides information about the provisions of the 
     quality assurance required under clauses (i) through (iii) to 
     each individual receiving such services; and
       ``(E) collect and report information, as determined 
     necessary by the Secretary, for the purposes of approving the 
     State plan amendment, providing Federal oversight, and 
     conducting an evaluation under paragraph (5)(A), including 
     data regarding how the State provides home and community-
     based attendant services and supports and other home and 
     community-based services, the cost of such services and 
     supports, and how the State provides individuals with 
     disabilities who otherwise qualify for institutional care 
     under the State plan or under a waiver the choice to instead 
     receive home and community-based services in lieu of 
     institutional care.
       ``(4) Compliance with certain laws.--A State shall ensure 
     that, regardless of whether the State uses an agency-provider 
     model or other models to provide home and community-based 
     attendant services and supports under a State plan amendment 
     under this subsection, such services and supports are 
     provided in accordance with the requirements of the Fair 
     Labor Standards Act of 1938 and applicable Federal and State 
     laws regarding--
       ``(A) withholding and payment of Federal and State income 
     and payroll taxes;
       ``(B) the provision of unemployment and workers 
     compensation insurance;
       ``(C) maintenance of general liability insurance; and
       ``(D) occupational health and safety.
       ``(5) Evaluation, data collection, and report to 
     congress.--
       ``(A) Evaluation.--The Secretary shall conduct an 
     evaluation of the provision of home and community-based 
     attendant services and supports under this subsection in 
     order to determine the effectiveness of the provision of such 
     services and supports in allowing the individuals receiving 
     such services and supports to lead an independent life to the 
     maximum extent possible; the impact on the physical and 
     emotional health of the individuals who receive such 
     services; and an comparative analysis of the costs of 
     services provided under the State plan amendment under this 
     subsection and those provided under institutional care in a 
     nursing facility, institution for mental diseases, or an 
     intermediate care facility for the mentally retarded.
       ``(B) Data collection.--The State shall provide the 
     Secretary with the following information regarding the 
     provision of home and community-based attendant services and 
     supports under this subsection for each fiscal year for which 
     such services and supports are provided:
       ``(i) The number of individuals who are estimated to 
     receive home and community-based attendant services and 
     supports under this subsection during the fiscal year.
       ``(ii) The number of individuals that received such 
     services and supports during the preceding fiscal year.
       ``(iii) The specific number of individuals served by type 
     of disability, age, gender, education level, and employment 
     status.
       ``(iv) Whether the specific individuals have been 
     previously served under any other home and community based 
     services program under the State plan or under a waiver.
       ``(C) Reports.--Not later than--
       ``(i) December 31, 2013, the Secretary shall submit to 
     Congress and make available to the public an interim report 
     on the findings of the evaluation under subparagraph (A); and
       ``(ii) December 31, 2015, the Secretary shall submit to 
     Congress and make available to the public a final report on 
     the findings of the evaluation under subparagraph (A).
       ``(6) Definitions.--In this subsection:
       ``(A) Activities of daily living.--The term `activities of 
     daily living' includes tasks such as eating, toileting, 
     grooming, dressing, bathing, and transferring.
       ``(B) Consumer controlled.--The term `consumer controlled' 
     means a method of selecting and providing services and 
     supports that allow the individual, or where appropriate, the 
     individual's representative, maximum control of the home and 
     community-based attendant services and supports, regardless 
     of who acts as the employer of record.
       ``(C) Delivery models.--
       ``(i) Agency-provider model.--The term `agency-provider 
     model' means, with respect to the provision of home and 
     community-based attendant services and supports for an 
     individual, subject to paragraph (4), a method of providing 
     consumer controlled services and supports under which 
     entities contract for the provision of such services and 
     supports.
       ``(ii) Other models.--The term `other models' means, 
     subject to paragraph (4), methods, other than an agency-
     provider model, for the provision of consumer controlled 
     services and supports. Such models may include the provision 
     of vouchers, direct cash payments, or use of a fiscal agent 
     to assist in obtaining services.
       ``(D) Health-related tasks.--The term `health-related 
     tasks' means specific tasks related to the needs of an 
     individual, which can be delegated or assigned by licensed 
     health-care professionals under State law to be performed by 
     an attendant.
       ``(E) Individual's representative.--The term `individual's 
     representative' means a parent, family member, guardian, 
     advocate, or other authorized representative of an 
     individual.
       ``(F) Instrumental activities of daily living.--The term 
     `instrumental activities of daily living' includes (but is 
     not limited to) meal planning and preparation, managing 
     finances, shopping for food, clothing, and other essential 
     items, performing essential household chores, communicating 
     by phone or other media, and traveling around and 
     participating in the community.''.

     SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND 
                   COMMUNITY-BASED SERVICES.

       (a) Oversight and Assessment of the Administration of Home 
     and Community-based Services.--The Secretary of Health and 
     Human Services shall promulgate regulations to ensure that 
     all States develop service systems that are designed to--
       (1) allocate resources for services in a manner that is 
     responsive to the changing needs and choices of beneficiaries 
     receiving non-institutionally-based long-term services and 
     supports (including such services and supports that are 
     provided under programs other the State Medicaid program), 
     and that provides strategies for beneficiaries receiving such 
     services to maximize their independence, including through 
     the use of client-employed providers;
       (2) provide the support and coordination needed for a 
     beneficiary in need of such services (and their family 
     caregivers or representative, if applicable) to design an 
     individualized, self-directed, community-supported life; and
       (3) improve coordination among, and the regulation of, all 
     providers of such services under federally and State-funded 
     programs in order to--
       (A) achieve a more consistent administration of policies 
     and procedures across programs in relation to the provision 
     of such services; and
       (B) oversee and monitor all service system functions to 
     assure--
       (i) coordination of, and effectiveness of, eligibility 
     determinations and individual assessments;
       (ii) development and service monitoring of a complaint 
     system, a management system, a system to qualify and monitor 
     providers, and systems for role-setting and individual budget 
     determinations; and
       (iii) an adequate number of qualified direct care workers 
     to provide self-directed personal assistance services.
       (b) Additional State Options.--Section 1915(i) of the 
     Social Security Act (42 U.S.C. 1396n(i)) is amended by adding 
     at the end the following new paragraphs:
       ``(6) State option to provide home and community-based 
     services to individuals eligible for services under a 
     waiver.--
       ``(A) In general.--A State that provides home and 
     community-based services in accordance with this subsection 
     to individuals who satisfy the needs-based criteria for the 
     receipt of such services established under paragraph (1)(A) 
     may, in addition to continuing to provide such services to 
     such individuals, elect to provide home and community-based 
     services in accordance with the requirements of this 
     paragraph to individuals who are eligible for home and 
     community-based services under a waiver approved for the 
     State under subsection (c), (d), or (e) or under section 1115 
     to provide such services, but only for those individuals 
     whose income does not exceed 300 percent of the supplemental 
     security income benefit rate established by section 
     1611(b)(1).
       ``(B) Application of same requirements for individuals 
     satisfying needs-based criteria.--Subject to subparagraph 
     (C), a State shall provide home and community-based services 
     to individuals under this paragraph in the same manner and 
     subject to the same requirements as apply under the other 
     paragraphs of this subsection to the provision of home and 
     community-based services to individuals who satisfy the 
     needs-based criteria established under paragraph (1)(A).
       ``(C) Authority to offer different type, amount, duration, 
     or scope of home and community-based services.--A State may 
     offer home and community-based services to individuals under 
     this paragraph that differ in type, amount, duration, or 
     scope from the home and community-based services offered for 
     individuals who satisfy the needs-based criteria established 
     under paragraph (1)(A), so long as such services are within 
     the scope of services described in

[[Page 4253]]

     paragraph (4)(B) of subsection (c) for which the Secretary 
     has the authority to approve a waiver and do not include room 
     or board.
       ``(7) State option to offer home and community-based 
     services to specific, targeted populations.--
       ``(A) In general.--A State may elect in a State plan 
     amendment under this subsection to target the provision of 
     home and community-based services under this subsection to 
     specific populations and to differ the type, amount, 
     duration, or scope of such services to such specific 
     populations.
       ``(B) 5-year term.--
       ``(i) In general.--An election by a State under this 
     paragraph shall be for a period of 5 years.
       ``(ii) Phase-in of services and eligibility permitted 
     during initial 5-year period.--A State making an election 
     under this paragraph may, during the first 5-year period for 
     which the election is made, phase-in the enrollment of 
     eligible individuals, or the provision of services to such 
     individuals, or both, so long as all eligible individuals in 
     the State for such services are enrolled, and all such 
     services are provided, before the end of the initial 5-year 
     period.
       ``(C) Renewal.--An election by a State under this paragraph 
     may be renewed for additional 5-year terms if the Secretary 
     determines, prior to beginning of each such renewal period, 
     that the State has--
       ``(i) adhered to the requirements of this subsection and 
     paragraph in providing services under such an election; and
       ``(ii) met the State's objectives with respect to quality 
     improvement and beneficiary outcomes.''.
       (c) Removal of Limitation on Scope of Services.--Paragraph 
     (1) of section 1915(i) of the Social Security Act (42 U.S.C. 
     1396n(i)), as amended by subsection (a), is amended by 
     striking ``or such other services requested by the State as 
     the Secretary may approve''.
       (d) Optional Eligibility Category To Provide Full Medicaid 
     Benefits to Individuals Receiving Home and Community-based 
     Services Under a State Plan Amendment.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
     section 2304(a)(1), is amended--
       (A) in subclause (XX), by striking ``or'' at the end;
       (B) in subclause (XXI), by adding ``or'' at the end; and
       (C) by inserting after subclause (XXI), the following new 
     subclause:

       ``(XXII) who are eligible for home and community-based 
     services under needs-based criteria established under 
     paragraph (1)(A) of section 1915(i), or who are eligible for 
     home and community-based services under paragraph (6) of such 
     section, and who will receive home and community-based 
     services pursuant to a State plan amendment under such 
     subsection;''.

       (2) Conforming amendments.--
       (A) Section 1903(f)(4) of the Social Security Act (42 
     U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), is 
     amended in the matter preceding subparagraph (A), by 
     inserting ``1902(a)(10)(A)(ii)(XXII),'' after 
     ``1902(a)(10)(A)(ii)(XXI),''.
       (B) Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)), as so amended, is amended in the matter preceding 
     paragraph (1)--
       (i) in clause (xv), by striking ``or'' at the end;
       (ii) in clause (xvi), by adding ``or'' at the end; and
       (iii) by inserting after clause (xvi) the following new 
     clause:
       ``(xvii) individuals who are eligible for home and 
     community-based services under needs-based criteria 
     established under paragraph (1)(A) of section 1915(i), or who 
     are eligible for home and community-based services under 
     paragraph (6) of such section, and who will receive home and 
     community-based services pursuant to a State plan amendment 
     under such subsection,''.
       (e) Elimination of Option To Limit Number of Eligible 
     Individuals or Length of Period for Grandfathered Individuals 
     if Eligibility Criteria Is Modified.--Paragraph (1) of 
     section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended--
       (1) by striking subparagraph (C) and inserting the 
     following:
       ``(C) Projection of number of individuals to be provided 
     home and community-based services.--The State submits to the 
     Secretary, in such form and manner, and upon such frequency 
     as the Secretary shall specify, the projected number of 
     individuals to be provided home and community-based 
     services.''; and
       (2) in subclause (II) of subparagraph (D)(ii), by striking 
     ``to be eligible for such services for a period of at least 
     12 months beginning on the date the individual first received 
     medical assistance for such services'' and inserting ``to 
     continue to be eligible for such services after the effective 
     date of the modification and until such time as the 
     individual no longer meets the standard for receipt of such 
     services under such pre-modified criteria''.
       (f) Elimination of Option To Waive Statewideness; Addition 
     of Option To Waive Comparability.--Paragraph (3) of section 
     1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by 
     striking ``1902(a)(1) (relating to statewideness)'' and 
     inserting ``1902(a)(10)(B) (relating to comparability)''.
       (g) Effective Date.--The amendments made by subsections (b) 
     through (f) take effect on the first day of the first fiscal 
     year quarter that begins after the date of enactment of this 
     Act.

     SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING 
                   DEMONSTRATION.

       (a) Extension of Demonstration.--
       (1) In general.--Section 6071(h) of the Deficit Reduction 
     Act of 2005 (42 U.S.C. 1396a note) is amended--
       (A) in paragraph (1)(E), by striking ``fiscal year 2011'' 
     and inserting ``each of fiscal years 2011 through 2016''; and
       (B) in paragraph (2), by striking ``2011'' and inserting 
     ``2016''.
       (2) Evaluation.--Paragraphs (2) and (3) of section 6071(g) 
     of such Act is amended are each amended by striking ``2011'' 
     and inserting ``2016''.
       (b) Reduction of Institutional Residency Period.--
       (1) In general.--Section 6071(b)(2) of the Deficit 
     Reduction Act of 2005 (42 U.S.C. 1396a note) is amended--
       (A) in subparagraph (A)(i), by striking ``, for a period of 
     not less than 6 months or for such longer minimum period, not 
     to exceed 2 years, as may be specified by the State'' and 
     inserting ``for a period of not less than 90 consecutive 
     days''; and
       (B) by adding at the end the following:

     ``Any days that an individual resides in an institution on 
     the basis of having been admitted solely for purposes of 
     receiving short-term rehabilitative services for a period for 
     which payment for such services is limited under title XVIII 
     shall not be taken into account for purposes of determining 
     the 90-day period required under subparagraph (A)(i).''.
       (2) Effective date.--The amendments made by this subsection 
     take effect 30 days after the date of enactment of this Act.

     SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-
                   BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT.

       During the 5-year period that begins on January 1, 2014, 
     section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 
     1396r-5(h)(1)(A)) shall be applied as though ``is eligible 
     for medical assistance for home and community-based services 
     provided under subsection (c), (d), or (i) of section 1915, 
     under a waiver approved under section 1115, or who is 
     eligible for such medical assistance by reason of being 
     determined eligible under section 1902(a)(10)(C) or by reason 
     of section 1902(f) or otherwise on the basis of a reduction 
     of income based on costs incurred for medical or other 
     remedial care, or who is eligible for medical assistance for 
     home and community-based attendant services and supports 
     under section 1915(k)'' were substituted in such section for 
     ``(at the option of the State) is described in section 
     1902(a)(10)(A)(ii)(VI)''.

     SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY 
                   RESOURCE CENTERS.

       Out of any funds in the Treasury not otherwise 
     appropriated, there is appropriated to the Secretary of 
     Health and Human Services, acting through the Assistant 
     Secretary for Aging, $10,000,000 for each of fiscal years 
     2010 through 2014, to carry out subsections (a)(20)(B)(iii) 
     and (b)(8) of section 202 of the Older Americans Act of 1965 
     (42 U.S.C. 3012).

     SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE.

       (a) Findings.--The Senate makes the following findings:
       (1) Nearly 2 decades have passed since Congress seriously 
     considered long-term care reform. The United States 
     Bipartisan Commission on Comprehensive Health Care, also know 
     as the ``Pepper Commission'', released its ``Call for 
     Action'' blueprint for health reform in September 1990. In 
     the 20 years since those recommendations were made, Congress 
     has never acted on the report.
       (2) In 1999, under the United States Supreme Court's 
     decision in Olmstead v. L.C., 527 U.S. 581 (1999), 
     individuals with disabilities have the right to choose to 
     receive their long-term services and supports in the 
     community, rather than in an institutional setting.
       (3) Despite the Pepper Commission and Olmstead decision, 
     the long-term care provided to our Nation's elderly and 
     disabled has not improved. In fact, for many, it has gotten 
     far worse.
       (4) In 2007, 69 percent of Medicaid long-term care spending 
     for elderly individuals and adults with physical disabilities 
     paid for institutional services. Only 6 states spent 50 
     percent or more of their Medicaid long-term care dollars on 
     home and community-based services for elderly individuals and 
     adults with physical disabilities while \1/2\ of the States 
     spent less than 25 percent. This disparity continues even 
     though, on average, it is estimated that Medicaid dollars can 
     support nearly 3 elderly individuals and adults with physical 
     disabilities in home and community-based services for every 
     individual in a nursing home. Although every State has chosen 
     to provide certain services under home and community-based 
     waivers, these services are unevenly available within and 
     across States, and reach a small percentage of eligible 
     individuals.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that--
       (1) during the 111th session of Congress, Congress should 
     address long-term services and supports in a comprehensive 
     way that guarantees elderly and disabled individuals the care 
     they need; and
       (2) long term services and supports should be made 
     available in the community in addition to in institutions.

            Subtitle F--Medicaid Prescription Drug Coverage

     SEC. 2501. PRESCRIPTION DRUG REBATES.

       (a) Increase in Minimum Rebate Percentage for Single Source 
     Drugs and Innovator Multiple Source Drugs.--

[[Page 4254]]

       (1) In general.--Section 1927(c)(1)(B) of the Social 
     Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended--
       (A) in clause (i)--
       (i) in subclause (IV), by striking ``and'' at the end;
       (ii) in subclause (V)--

       (I) by inserting ``and before January 1, 2010'' after 
     ``December 31, 1995,''; and
       (II) by striking the period at the end and inserting ``; 
     and''; and

       (iii) by adding at the end the following new subclause:

       ``(VI) except as provided in clause (iii), after December 
     31, 2009, 23.1 percent.''; and

       (B) by adding at the end the following new clause:
       ``(iii) Minimum rebate percentage for certain drugs.--

       ``(I) In general.--In the case of a single source drug or 
     an innovator multiple source drug described in subclause 
     (II), the minimum rebate percentage for rebate periods 
     specified in clause (i)(VI) is 17.1 percent.
       ``(II) Drug described.--For purposes of subclause (I), a 
     single source drug or an innovator multiple source drug 
     described in this subclause is any of the following drugs:

       ``(aa) A clotting factor for which a separate furnishing 
     payment is made under section 1842(o)(5) and which is 
     included on a list of such factors specified and updated 
     regularly by the Secretary.
       ``(bb) A drug approved by the Food and Drug Administration 
     exclusively for pediatric indications.''.
       (2) Recapture of total savings due to increase.--Section 
     1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended 
     by adding at the end the following new subparagraph:
       ``(C) Special rule for increased minimum rebate 
     percentage.--
       ``(i) In general.--In addition to the amounts applied as a 
     reduction under subparagraph (B), for rebate periods 
     beginning on or after January 1, 2010, during a fiscal year, 
     the Secretary shall reduce payments to a State under section 
     1903(a) in the manner specified in clause (ii), in an amount 
     equal to the product of--

       ``(I) 100 percent minus the Federal medical assistance 
     percentage applicable to the rebate period for the State; and
       ``(II) the amounts received by the State under such 
     subparagraph that are attributable (as estimated by the 
     Secretary based on utilization and other data) to the 
     increase in the minimum rebate percentage effected by the 
     amendments made by subsections (a)(1), (b), and (d) of 
     section 2501 of the Patient Protection and Affordable Care 
     Act, taking into account the additional drugs included under 
     the amendments made by subsection (c) of section 2501 of such 
     Act.

     The Secretary shall adjust such payment reduction for a 
     calendar quarter to the extent the Secretary determines, 
     based upon subsequent utilization and other data, that the 
     reduction for such quarter was greater or less than the 
     amount of payment reduction that should have been made.
       ``(ii) Manner of payment reduction.--The amount of the 
     payment reduction under clause (i) for a State for a quarter 
     shall be deemed an overpayment to the State under this title 
     to be disallowed against the State's regular quarterly draw 
     for all Medicaid spending under section 1903(d)(2). Such a 
     disallowance is not subject to a reconsideration under 
     section 1116(d).''.
       (b) Increase in Rebate for Other Drugs.--Section 
     1927(c)(3)(B) of such Act (42 U.S.C. 1396r-8(c)(3)(B)) is 
     amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) in clause (ii)--
       (A) by inserting ``and before January 1, 2010,'' after 
     ``December 31, 1993,''; and
       (B) by striking the period and inserting ``; and''; and
       (3) by adding at the end the following new clause:
       ``(iii) after December 31, 2009, is 13 percent.''.
       (c) Extension of Prescription Drug Discounts to Enrollees 
     of Medicaid Managed Care Organizations.--
       (1) In general.--Section 1903(m)(2)(A) of such Act (42 
     U.S.C. 1396b(m)(2)(A)) is amended--
       (A) in clause (xi), by striking ``and'' at the end;
       (B) in clause (xii), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(xiii) such contract provides that (I) covered outpatient 
     drugs dispensed to individuals eligible for medical 
     assistance who are enrolled with the entity shall be subject 
     to the same rebate required by the agreement entered into 
     under section 1927 as the State is subject to and that the 
     State shall collect such rebates from manufacturers, (II) 
     capitation rates paid to the entity shall be based on actual 
     cost experience related to rebates and subject to the Federal 
     regulations requiring actuarially sound rates, and (III) the 
     entity shall report to the State, on such timely and periodic 
     basis as specified by the Secretary in order to include in 
     the information submitted by the State to a manufacturer and 
     the Secretary under section 1927(b)(2)(A), information on the 
     total number of units of each dosage form and strength and 
     package size by National Drug Code of each covered outpatient 
     drug dispensed to individuals eligible for medical assistance 
     who are enrolled with the entity and for which the entity is 
     responsible for coverage of such drug under this subsection 
     (other than covered outpatient drugs that under subsection 
     (j)(1) of section 1927 are not subject to the requirements of 
     that section) and such other data as the Secretary determines 
     necessary to carry out this subsection.''.
       (2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-
     8) is amended--
       (A) in subsection (b)--
       (i) in paragraph (1)(A), in the first sentence, by 
     inserting ``, including such drugs dispensed to individuals 
     enrolled with a medicaid managed care organization if the 
     organization is responsible for coverage of such drugs'' 
     before the period; and
       (ii) in paragraph (2)(A), by inserting ``including such 
     information reported by each medicaid managed care 
     organization,'' after ``for which payment was made under the 
     plan during the period,''; and
       (B) in subsection (j), by striking paragraph (1) and 
     inserting the following:
       ``(1) Covered outpatient drugs are not subject to the 
     requirements of this section if such drugs are--
       ``(A) dispensed by health maintenance organizations, 
     including Medicaid managed care organizations that contract 
     under section 1903(m); and
       ``(B) subject to discounts under section 340B of the Public 
     Health Service Act.''.
       (d) Additional Rebate for New Formulations of Existing 
     Drugs.--
       (1) In general.--Section 1927(c)(2) of the Social Security 
     Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end 
     the following new subparagraph:
       ``(C) Treatment of new formulations.--
       ``(i) In general.--Except as provided in clause (ii), in 
     the case of a drug that is a new formulation, such as an 
     extended-release formulation, of a single source drug or an 
     innovator multiple source drug, the rebate obligation with 
     respect to the drug under this section shall be the amount 
     computed under this section for the new formulation of the 
     drug or, if greater, the product of--

       ``(I) the average manufacturer price for each dosage form 
     and strength of the new formulation of the single source drug 
     or innovator multiple source drug;
       ``(II) the highest additional rebate (calculated as a 
     percentage of average manufacturer price) under this section 
     for any strength of the original single source drug or 
     innovator multiple source drug; and
       ``(III) the total number of units of each dosage form and 
     strength of the new formulation paid for under the State plan 
     in the rebate period (as reported by the State).

       ``(ii) No application to new formulations of orphan 
     drugs.--Clause (i) shall not apply to a new formulation of a 
     covered outpatient drug that is or has been designated under 
     section 526 of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 360bb) for a rare disease or condition, without regard 
     to whether the period of market exclusivity for the drug 
     under section 527 of such Act has expired or the specific 
     indication for use of the drug.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to drugs that are paid for by a State after 
     December 31, 2009.
       (e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act 
     (42 U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is 
     amended by adding at the end the following new subparagraph:
       ``(D) Maximum rebate amount.--In no case shall the sum of 
     the amounts applied under paragraph (1)(A)(ii) and this 
     paragraph with respect to each dosage form and strength of a 
     single source drug or an innovator multiple source drug for a 
     rebate period beginning after December 31, 2009, exceed 100 
     percent of the average manufacturer price of the drug.''.
       (f) Conforming Amendments.--
       (1) In general.--Section 340B of the Public Health Service 
     Act (42 U.S.C. 256b) is amended--
       (A) in subsection (a)(2)(B)(i), by striking ``1927(c)(4)'' 
     and inserting ``1927(c)(3)''; and
       (B) by striking subsection (c); and
       (C) redesignating subsection (d) as subsection (c).
       (2) Effective date.--The amendments made by this subsection 
     take effect on January 1, 2010.

     SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN 
                   DRUGS.

       (a) In General.--Section 1927(d) of the Social Security Act 
     (42 U.S.C. 1397r-8(d)) is amended--
       (1) in paragraph (2)--
       (A) by striking subparagraphs (E), (I), and (J), 
     respectively; and
       (B) by redesignating subparagraphs (F), (G), (H), and (K) 
     as subparagraphs (E), (F), (G), and (H), respectively; and
       (2) by adding at the end the following new paragraph:
       ``(7) Non-excludable drugs.--The following drugs or classes 
     of drugs, or their medical uses, shall not be excluded from 
     coverage:
       ``(A) Agents when used to promote smoking cessation, 
     including agents approved by the Food and Drug Administration 
     under the over-the-counter monograph process for purposes of 
     promoting, and when used to promote, tobacco cessation.
       ``(B) Barbiturates.
       ``(C) Benzodiazepines.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2014.

     SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT.

       (a) Pharmacy Reimbursement Limits.--
       (1) In general.--Section 1927(e) of the Social Security Act 
     (42 U.S.C. 1396r-8(e)) is amended--
       (A) in paragraph (4), by striking ``(or, effective January 
     1, 2007, two or more)''; and
       (B) by striking paragraph (5) and inserting the following:

[[Page 4255]]

       ``(5) Use of amp in upper payment limits.--The Secretary 
     shall calculate the Federal upper reimbursement limit 
     established under paragraph (4) as no less than 175 percent 
     of the weighted average (determined on the basis of 
     utilization) of the most recently reported monthly average 
     manufacturer prices for pharmaceutically and therapeutically 
     equivalent multiple source drug products that are available 
     for purchase by retail community pharmacies on a nationwide 
     basis. The Secretary shall implement a smoothing process for 
     average manufacturer prices. Such process shall be similar to 
     the smoothing process used in determining the average sales 
     price of a drug or biological under section 1847A.''.
       (2) Definition of amp.--Section 1927(k)(1) of such Act (42 
     U.S.C. 1396r-8(k)(1)) is amended--
       (A) in subparagraph (A), by striking ``by'' and all that 
     follows through the period and inserting ``by--
       ``(i) wholesalers for drugs distributed to retail community 
     pharmacies; and
       ``(ii) retail community pharmacies that purchase drugs 
     directly from the manufacturer.''; and
       (B) by striking subparagraph (B) and inserting the 
     following:
       ``(B) Exclusion of customary prompt pay discounts and other 
     payments.--
       ``(i) In general.--The average manufacturer price for a 
     covered outpatient drug shall exclude--

       ``(I) customary prompt pay discounts extended to 
     wholesalers;
       ``(II) bona fide service fees paid by manufacturers to 
     wholesalers or retail community pharmacies, including (but 
     not limited to) distribution service fees, inventory 
     management fees, product stocking allowances, and fees 
     associated with administrative services agreements and 
     patient care programs (such as medication compliance programs 
     and patient education programs);
       ``(III) reimbursement by manufacturers for recalled, 
     damaged, expired, or otherwise unsalable returned goods, 
     including (but not limited to) reimbursement for the cost of 
     the goods and any reimbursement of costs associated with 
     return goods handling and processing, reverse logistics, and 
     drug destruction; and
       ``(IV) payments received from, and rebates or discounts 
     provided to, pharmacy benefit managers, managed care 
     organizations, health maintenance organizations, insurers, 
     hospitals, clinics, mail order pharmacies, long term care 
     providers, manufacturers, or any other entity that does not 
     conduct business as a wholesaler or a retail community 
     pharmacy.

       ``(ii) Inclusion of other discounts and payments.--
     Notwithstanding clause (i), any other discounts, rebates, 
     payments, or other financial transactions that are received 
     by, paid by, or passed through to, retail community 
     pharmacies shall be included in the average manufacturer 
     price for a covered outpatient drug.''; and
       (C) in subparagraph (C), by striking ``the retail pharmacy 
     class of trade'' and inserting ``retail community 
     pharmacies''.
       (3) Definition of multiple source drug.--Section 1927(k)(7) 
     of such Act (42 U.S.C. 1396r-8(k)(7)) is amended--
       (A) in subparagraph (A)(i)(III), by striking ``the State'' 
     and inserting ``the United States''; and
       (B) in subparagraph (C)--
       (i) in clause (i), by inserting ``and'' after the 
     semicolon;
       (ii) in clause (ii), by striking ``; and'' and inserting a 
     period; and
       (iii) by striking clause (iii).
       (4) Definitions of retail community pharmacy; wholesaler.--
     Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended 
     by adding at the end the following new paragraphs:
       ``(10) Retail community pharmacy.--The term `retail 
     community pharmacy' means an independent pharmacy, a chain 
     pharmacy, a supermarket pharmacy, or a mass merchandiser 
     pharmacy that is licensed as a pharmacy by the State and that 
     dispenses medications to the general public at retail prices. 
     Such term does not include a pharmacy that dispenses 
     prescription medications to patients primarily through the 
     mail, nursing home pharmacies, long-term care facility 
     pharmacies, hospital pharmacies, clinics, charitable or not-
     for-profit pharmacies, government pharmacies, or pharmacy 
     benefit managers.
       ``(11) Wholesaler.--The term `wholesaler' means a drug 
     wholesaler that is engaged in wholesale distribution of 
     prescription drugs to retail community pharmacies, including 
     (but not limited to) manufacturers, repackers, distributors, 
     own-label distributors, private-label distributors, jobbers, 
     brokers, warehouses (including manufacturer's and 
     distributor's warehouses, chain drug warehouses, and 
     wholesale drug warehouses) independent wholesale drug 
     traders, and retail community pharmacies that conduct 
     wholesale distributions.''.
       (b) Disclosure of Price Information to the Public.--Section 
     1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
       (1) in subparagraph (A)--
       (A) in the first sentence, by inserting after clause (iii) 
     the following:
       ``(iv) not later than 30 days after the last day of each 
     month of a rebate period under the agreement, on the 
     manufacturer's total number of units that are used to 
     calculate the monthly average manufacturer price for each 
     covered outpatient drug;''; and
       (B) in the second sentence, by inserting ``(relating to the 
     weighted average of the most recently reported monthly 
     average manufacturer prices)'' after ``(D)(v)''; and
       (2) in subparagraph (D)(v), by striking ``average 
     manufacturer prices'' and inserting ``the weighted average of 
     the most recently reported monthly average manufacturer 
     prices and the average retail survey price determined for 
     each multiple source drug in accordance with subsection 
     (f)''.
       (c) Clarification of Application of Survey of Retail 
     Prices.--Section 1927(f)(1) of such Act (42 U.S.C. 1396r-
     8(b)(1)) is amended--
       (1) in subparagraph (A)(i), by inserting ``with respect to 
     a retail community pharmacy,'' before ``the determination''; 
     and
       (2) in subparagraph (C)(ii), by striking ``retail 
     pharmacies'' and inserting ``retail community pharmacies''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on the first day of the first calendar year 
     quarter that begins at least 180 days after the date of 
     enactment of this Act, without regard to whether or not final 
     regulations to carry out such amendments have been 
     promulgated by such date.

  Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments

     SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.

       (a) In General.--Section 1923(f) of the Social Security Act 
     (42 U.S.C. 1396r-4(f)) is amended--
       (1) in paragraph (1), by striking ``and (3)'' and inserting 
     ``, (3), and (7)'';
       (2) in paragraph (3)(A), by striking ``paragraph (6)'' and 
     inserting ``paragraphs (6) and (7)'';
       (3) by redesignating paragraph (7) as paragraph (8); and
       (4) by inserting after paragraph (6) the following new 
     paragraph:
       ``(7) Reduction of state dsh allotments once reduction in 
     uninsured threshold reached.--
       ``(A) In general.--Subject to subparagraph (E), the DSH 
     allotment for a State for fiscal years beginning with the 
     fiscal year described in subparagraph (C) (with respect to 
     the State), is equal to--
       ``(i) in the case of the first fiscal year described in 
     subparagraph (C) with respect to a State, the DSH allotment 
     that would be determined under this subsection for the State 
     for the fiscal year without application of this paragraph 
     (but after the application of subparagraph (D)), reduced by 
     the applicable percentage determined for the State for the 
     fiscal year under subparagraph (B)(i); and
       ``(ii) in the case of any subsequent fiscal year with 
     respect to the State, the DSH allotment determined under this 
     paragraph for the State for the preceding fiscal year, 
     reduced by the applicable percentage determined for the State 
     for the fiscal year under subparagraph (B)(ii).
       ``(B) Applicable percentage.--For purposes of subparagraph 
     (A), the applicable percentage for a State for a fiscal year 
     is the following:
       ``(i) Uninsured reduction threshold fiscal year.--In the 
     case of the first fiscal year described in subparagraph (C) 
     with respect to the State--

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B), the applicable percentage is equal to 25 
     percent; and
       ``(II) if the State is any other State, the applicable 
     percentage is 50 percent.

       ``(ii) Subsequent fiscal years in which the percentage of 
     uninsured decreases.--In the case of any fiscal year after 
     the first fiscal year described in subparagraph (C) with 
     respect to a State, if the Secretary determines on the basis 
     of the most recent American Community Survey of the Bureau of 
     the Census, that the percentage of uncovered individuals 
     residing in the State is less than the percentage of such 
     individuals determined for the State for the preceding fiscal 
     year--

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B), the applicable percentage is equal to the 
     product of the percentage reduction in uncovered individuals 
     for the fiscal year from the preceding fiscal year and 25 
     percent; and
       ``(II) if the State is any other State, the applicable 
     percentage is equal to the product of the percentage 
     reduction in uncovered individuals for the fiscal year from 
     the preceding fiscal year and 50 percent.

       ``(C) Fiscal year described.--For purposes of subparagraph 
     (A), the fiscal year described in this subparagraph with 
     respect to a State is the first fiscal year that occurs after 
     fiscal year 2012 for which the Secretary determines, on the 
     basis of the most recent American Community Survey of the 
     Bureau of the Census, that the percentage of uncovered 
     individuals residing in the State is at least 45 percent less 
     than the percentage of such individuals determined for the 
     State for fiscal year 2009.
       ``(D) Exclusion of portions diverted for coverage 
     expansions.--For purposes of applying the applicable 
     percentage reduction under subparagraph (A) to the DSH 
     allotment for a State for a fiscal year, the DSH allotment 
     for a State that would be determined under this subsection 
     for the State for the fiscal year without the application of 
     this paragraph (and prior to any such reduction) shall not 
     include any portion of the allotment for which the Secretary 
     has approved the State's diversion to the costs of providing 
     medical assistance or other health benefits coverage under a 
     waiver that is in effect on July 2009.
       ``(E) Minimum allotment.--In no event shall the DSH 
     allotment determined for a State in accordance with this 
     paragraph for fiscal year 2013 or any succeeding fiscal year 
     be less than the amount equal to 35 percent of the DSH 
     allotment determined for the State for fiscal year

[[Page 4256]]

     2012 under this subsection (and after the application of this 
     paragraph, if applicable), increased by the percentage change 
     in the consumer price index for all urban consumers (all 
     items, U.S. city average) for each previous fiscal year 
     occurring before the fiscal year.
       ``(F) Uncovered individuals.--In this paragraph, the term 
     `uncovered individuals' means individuals with no health 
     insurance coverage at any time during a year (as determined 
     by the Secretary based on the most recent data available).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     take effect on October 1, 2011.

   Subtitle H--Improved Coordination for Dual Eligible Beneficiaries

     SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS.

       (a) In General.--Section 1915(h) of the Social Security Act 
     (42 U.S.C. 1396n(h)) is amended--
       (1) by inserting ``(1)'' after ``(h)'';
       (2) by inserting ``, or a waiver described in paragraph 
     (2)'' after ``(e)''; and
       (3) by adding at the end the following new paragraph:
       ``(2)(A) Notwithstanding subsections (c)(3) and (d) (3), 
     any waiver under subsection (b), (c), or (d), or a waiver 
     under section 1115, that provides medical assistance for dual 
     eligible individuals (including any such waivers under which 
     non dual eligible individuals may be enrolled in addition to 
     dual eligible individuals) may be conducted for a period of 5 
     years and, upon the request of the State, may be extended for 
     additional 5-year periods unless the Secretary determines 
     that for the previous waiver period the conditions for the 
     waiver have not been met or it would no longer be cost-
     effective and efficient, or consistent with the purposes of 
     this title, to extend the waiver.
       ``(B) In this paragraph, the term `dual eligible 
     individual' means an individual who is entitled to, or 
     enrolled for, benefits under part A of title XVIII, or 
     enrolled for benefits under part B of title XVIII, and is 
     eligible for medical assistance under the State plan under 
     this title or under a waiver of such plan.''.
       (b) Conforming Amendments.--
       (1) Section 1915 of such Act (42 U.S.C. 1396n) is amended--
       (A) in subsection (b), by adding at the end the following 
     new sentence: ``Subsection (h)(2) shall apply to a waiver 
     under this subsection.'';
       (B) in subsection (c)(3), in the second sentence, by 
     inserting ``(other than a waiver described in subsection 
     (h)(2))'' after ``A waiver under this subsection'';
       (C) in subsection (d)(3), in the second sentence, by 
     inserting ``(other than a waiver described in subsection 
     (h)(2))'' after ``A waiver under this subsection''.
       (2) Section 1115 of such Act (42 U.S.C. 1315) is amended--
       (A) in subsection (e)(2), by inserting ``(5 years, in the 
     case of a waiver described in section 1915(h)(2))'' after ``3 
     years''; and
       (B) in subsection (f)(6), by inserting ``(5 years, in the 
     case of a waiver described in section 1915(h)(2))'' after ``3 
     years''.

     SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT 
                   COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES.

       (a) Establishment of Federal Coordinated Health Care 
     Office.--
       (1) In general.--Not later than March 1, 2010, the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall establish a Federal 
     Coordinated Health Care Office.
       (2) Establishment and reporting to cms administrator.--The 
     Federal Coordinated Health Care Office--
       (A) shall be established within the Centers for Medicare & 
     Medicaid Services; and
       (B) have as the Office a Director who shall be appointed 
     by, and be in direct line of authority to, the Administrator 
     of the Centers for Medicare & Medicaid Services.
       (b) Purpose.--The purpose of the Federal Coordinated Health 
     Care Office is to bring together officers and employees of 
     the Medicare and Medicaid programs at the Centers for 
     Medicare & Medicaid Services in order to--
       (1) more effectively integrate benefits under the Medicare 
     program under title XVIII of the Social Security Act and the 
     Medicaid program under title XIX of such Act; and
       (2) improve the coordination between the Federal Government 
     and States for individuals eligible for benefits under both 
     such programs in order to ensure that such individuals get 
     full access to the items and services to which they are 
     entitled under titles XVIII and XIX of the Social Security 
     Act.
       (c) Goals.--The goals of the Federal Coordinated Health 
     Care Office are as follows:
       (1) Providing dual eligible individuals full access to the 
     benefits to which such individuals are entitled under the 
     Medicare and Medicaid programs.
       (2) Simplifying the processes for dual eligible individuals 
     to access the items and services they are entitled to under 
     the Medicare and Medicaid programs.
       (3) Improving the quality of health care and long-term 
     services for dual eligible individuals.
       (4) Increasing dual eligible individuals' understanding of 
     and satisfaction with coverage under the Medicare and 
     Medicaid programs.
       (5) Eliminating regulatory conflicts between rules under 
     the Medicare and Medicaid programs.
       (6) Improving care continuity and ensuring safe and 
     effective care transitions for dual eligible individuals.
       (7) Eliminating cost-shifting between the Medicare and 
     Medicaid program and among related health care providers.
       (8) Improving the quality of performance of providers of 
     services and suppliers under the Medicare and Medicaid 
     programs.
       (d) Specific Responsibilities.--The specific 
     responsibilities of the Federal Coordinated Health Care 
     Office are as follows:
       (1) Providing States, specialized MA plans for special 
     needs individuals (as defined in section 1859(b)(6) of the 
     Social Security Act (42 U.S.C. 1395w-28(b)(6))), physicians 
     and other relevant entities or individuals with the education 
     and tools necessary for developing programs that align 
     benefits under the Medicare and Medicaid programs for dual 
     eligible individuals.
       (2) Supporting State efforts to coordinate and align acute 
     care and long-term care services for dual eligible 
     individuals with other items and services furnished under the 
     Medicare program.
       (3) Providing support for coordination of contracting and 
     oversight by States and the Centers for Medicare & Medicaid 
     Services with respect to the integration of the Medicare and 
     Medicaid programs in a manner that is supportive of the goals 
     described in paragraph (3).
       (4) To consult and coordinate with the Medicare Payment 
     Advisory Commission established under section 1805 of the 
     Social Security Act (42 U.S.C. 1395b-6) and the Medicaid and 
     CHIP Payment and Access Commission established under section 
     1900 of such Act (42 U.S.C. 1396) with respect to policies 
     relating to the enrollment in, and provision of, benefits to 
     dual eligible individuals under the Medicare program under 
     title XVIII of the Social Security Act and the Medicaid 
     program under title XIX of such Act.
       (5) To study the provision of drug coverage for new full-
     benefit dual eligible individuals (as defined in section 
     1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
     5(c)(6)), as well as to monitor and report annual total 
     expenditures, health outcomes, and access to benefits for all 
     dual eligible individuals.
       (e) Report.--The Secretary shall, as part of the budget 
     transmitted under section 1105(a) of title 31, United States 
     Code, submit to Congress an annual report containing 
     recommendations for legislation that would improve care 
     coordination and benefits for dual eligible individuals.
       (f) Dual Eligible Defined.--In this section, the term 
     ``dual eligible individual'' means an individual who is 
     entitled to, or enrolled for, benefits under part A of title 
     XVIII of the Social Security Act, or enrolled for benefits 
     under part B of title XVIII of such Act, and is eligible for 
     medical assistance under a State plan under title XIX of such 
     Act or under a waiver of such plan.

    Subtitle I--Improving the Quality of Medicaid for Patients and 
                               Providers

     SEC. 2701. ADULT HEALTH QUALITY MEASURES.

       Title XI of the Social Security Act (42 U.S.C. 1301 et 
     seq.), as amended by section 401 of the Children's Health 
     Insurance Program Reauthorization Act of 2009 (Public Law 
     111-3), is amended by inserting after section 1139A the 
     following new section:

     ``SEC. 1139B. ADULT HEALTH QUALITY MEASURES.

       ``(a) Development of Core Set of Health Care Quality 
     Measures for Adults Eligible for Benefits Under Medicaid.--
     The Secretary shall identify and publish a recommended core 
     set of adult health quality measures for Medicaid eligible 
     adults in the same manner as the Secretary identifies and 
     publishes a core set of child health quality measures under 
     section 1139A, including with respect to identifying and 
     publishing existing adult health quality measures that are in 
     use under public and privately sponsored health care coverage 
     arrangements, or that are part of reporting systems that 
     measure both the presence and duration of health insurance 
     coverage over time, that may be applicable to Medicaid 
     eligible adults.
       ``(b) Deadlines.--
       ``(1) Recommended measures.--Not later than January 1, 
     2011, the Secretary shall identify and publish for comment a 
     recommended core set of adult health quality measures for 
     Medicaid eligible adults.
       ``(2) Dissemination.--Not later than January 1, 2012, the 
     Secretary shall publish an initial core set of adult health 
     quality measures that are applicable to Medicaid eligible 
     adults.
       ``(3) Standardized reporting.--Not later than January 1, 
     2013, the Secretary, in consultation with States, shall 
     develop a standardized format for reporting information based 
     on the initial core set of adult health quality measures and 
     create procedures to encourage States to use such measures to 
     voluntarily report information regarding the quality of 
     health care for Medicaid eligible adults.
       ``(4) Reports to congress.--Not later than January 1, 2014, 
     and every 3 years thereafter, the Secretary shall include in 
     the report to Congress required under section 1139A(a)(6) 
     information similar to the information required under that 
     section with respect to the measures established under this 
     section.
       ``(5) Establishment of medicaid quality measurement 
     program.--
       ``(A) In general.--Not later than 12 months after the 
     release of the recommended core set of adult health quality 
     measures under paragraph (1)), the Secretary shall establish 
     a Medicaid Quality Measurement Program in the same manner as 
     the Secretary establishes the pediatric quality measures 
     program under section 1139A(b). The aggregate amount awarded 
     by the Secretary for grants and contracts for the 
     development, testing, and validation of emerging and 
     innovative evidence-based measures under such program shall 
     equal the aggregate amount

[[Page 4257]]

     awarded by the Secretary for grants under section 
     1139A(b)(4)(A)
       ``(B) Revising, strengthening, and improving initial core 
     measures.--Beginning not later than 24 months after the 
     establishment of the Medicaid Quality Measurement Program, 
     and annually thereafter, the Secretary shall publish 
     recommended changes to the initial core set of adult health 
     quality measures that shall reflect the results of the 
     testing, validation, and consensus process for the 
     development of adult health quality measures.
       ``(c) Construction.--Nothing in this section shall be 
     construed as supporting the restriction of coverage, under 
     title XIX or XXI or otherwise, to only those services that 
     are evidence-based, or in anyway limiting available services.
       ``(d) Annual State Reports Regarding State-Specific Quality 
     of Care Measures Applied Under Medicaid.--
       ``(1) Annual state reports.--Each State with a State plan 
     or waiver approved under title XIX shall annually report 
     (separately or as part of the annual report required under 
     section 1139A(c)), to the Secretary on the--
       ``(A) State-specific adult health quality measures applied 
     by the State under the such plan, including measures 
     described in subsection (a)(5); and
       ``(B) State-specific information on the quality of health 
     care furnished to Medicaid eligible adults under such plan, 
     including information collected through external quality 
     reviews of managed care organizations under section 1932 and 
     benchmark plans under section 1937.
       ``(2) Publication.--Not later than September 30, 2014, and 
     annually thereafter, the Secretary shall collect, analyze, 
     and make publicly available the information reported by 
     States under paragraph (1).
       ``(e) Appropriation.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated for each of 
     fiscal years 2010 through 2014, $60,000,000 for the purpose 
     of carrying out this section. Funds appropriated under this 
     subsection shall remain available until expended.''.

     SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED 
                   CONDITIONS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this subsection referred to as the ``Secretary'') shall 
     identify current State practices that prohibit payment for 
     health care-acquired conditions and shall incorporate the 
     practices identified, or elements of such practices, which 
     the Secretary determines appropriate for application to the 
     Medicaid program in regulations. Such regulations shall be 
     effective as of July 1, 2011, and shall prohibit payments to 
     States under section 1903 of the Social Security Act for any 
     amounts expended for providing medical assistance for health 
     care-acquired conditions specified in the regulations. The 
     regulations shall ensure that the prohibition on payment for 
     health care-acquired conditions shall not result in a loss of 
     access to care or services for Medicaid beneficiaries.
       (b) Health Care-Acquired Condition.--In this section. the 
     term ``health care-acquired condition'' means a medical 
     condition for which an individual was diagnosed that could be 
     identified by a secondary diagnostic code described in 
     section 1886(d)(4)(D)(iv) of the Social Security Act (42 
     U.S.C. 1395ww(d)(4)(D)(iv)).
       (c) Medicare Provisions.--In carrying out this section, the 
     Secretary shall apply to State plans (or waivers) under title 
     XIX of the Social Security Act the regulations promulgated 
     pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C. 
     1395ww(d)(4)(D)) relating to the prohibition of payments 
     based on the presence of a secondary diagnosis code specified 
     by the Secretary in such regulations, as appropriate for the 
     Medicaid program. The Secretary may exclude certain 
     conditions identified under title XVIII of the Social 
     Security Act for non-payment under title XIX of such Act when 
     the Secretary finds the inclusion of such conditions to be 
     inapplicable to beneficiaries under title XIX.

     SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES 
                   WITH CHRONIC CONDITIONS.

       (a) State Plan Amendment.--Title XIX of the Social Security 
     Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 
     and 2305, is amended by adding at the end the following new 
     section:
       ``Sec. 1945. State Option To Provide Coordinated Care 
     Through a Health Home for Individuals With Chronic 
     Conditions.--
       ``(a) In General.--Notwithstanding section 1902(a)(1) 
     (relating to statewideness), section 1902(a)(10)(B) (relating 
     to comparability), and any other provision of this title for 
     which the Secretary determines it is necessary to waive in 
     order to implement this section, beginning January 1, 2011, a 
     State, at its option as a State plan amendment, may provide 
     for medical assistance under this title to eligible 
     individuals with chronic conditions who select a designated 
     provider (as described under subsection (h)(5)), a team of 
     health care professionals (as described under subsection 
     (h)(6)) operating with such a provider, or a health team (as 
     described under subsection (h)(7)) as the individual's health 
     home for purposes of providing the individual with health 
     home services.
       ``(b) Health Home Qualification Standards.--The Secretary 
     shall establish standards for qualification as a designated 
     provider for the purpose of being eligible to be a health 
     home for purposes of this section.
       ``(c) Payments.--
       ``(1) In general.--A State shall provide a designated 
     provider, a team of health care professionals operating with 
     such a provider, or a health team with payments for the 
     provision of health home services to each eligible individual 
     with chronic conditions that selects such provider, team of 
     health care professionals, or health team as the individual's 
     health home. Payments made to a designated provider, a team 
     of health care professionals operating with such a provider, 
     or a health team for such services shall be treated as 
     medical assistance for purposes of section 1903(a), except 
     that, during the first 8 fiscal year quarters that the State 
     plan amendment is in effect, the Federal medical assistance 
     percentage applicable to such payments shall be equal to 90 
     percent.
       ``(2) Methodology.--
       ``(A) In general.--The State shall specify in the State 
     plan amendment the methodology the State will use for 
     determining payment for the provision of health home 
     services. Such methodology for determining payment--
       ``(i) may be tiered to reflect, with respect to each 
     eligible individual with chronic conditions provided such 
     services by a designated provider, a team of health care 
     professionals operating with such a provider, or a health 
     team, as well as the severity or number of each such 
     individual's chronic conditions or the specific capabilities 
     of the provider, team of health care professionals, or health 
     team; and
       ``(ii) shall be established consistent with section 
     1902(a)(30)(A).
       ``(B) Alternate models of payment.--The methodology for 
     determining payment for provision of health home services 
     under this section shall not be limited to a per-member per-
     month basis and may provide (as proposed by the State and 
     subject to approval by the Secretary) for alternate models of 
     payment.
       ``(3) Planning grants.--
       ``(A) In general.--Beginning January 1, 2011, the Secretary 
     may award planning grants to States for purposes of 
     developing a State plan amendment under this section. A 
     planning grant awarded to a State under this paragraph shall 
     remain available until expended.
       ``(B) State contribution.--A State awarded a planning grant 
     shall contribute an amount equal to the State percentage 
     determined under section 1905(b) (without regard to section 
     5001 of Public Law 111-5) for each fiscal year for which the 
     grant is awarded.
       ``(C) Limitation.--The total amount of payments made to 
     States under this paragraph shall not exceed $25,000,000.
       ``(d) Hospital Referrals.--A State shall include in the 
     State plan amendment a requirement for hospitals that are 
     participating providers under the State plan or a waiver of 
     such plan to establish procedures for referring any eligible 
     individuals with chronic conditions who seek or need 
     treatment in a hospital emergency department to designated 
     providers.
       ``(e) Coordination.--A State shall consult and coordinate, 
     as appropriate, with the Substance Abuse and Mental Health 
     Services Administration in addressing issues regarding the 
     prevention and treatment of mental illness and substance 
     abuse among eligible individuals with chronic conditions.
       ``(f) Monitoring.--A State shall include in the State plan 
     amendment--
       ``(1) a methodology for tracking avoidable hospital 
     readmissions and calculating savings that result from 
     improved chronic care coordination and management under this 
     section; and
       ``(2) a proposal for use of health information technology 
     in providing health home services under this section and 
     improving service delivery and coordination across the care 
     continuum (including the use of wireless patient technology 
     to improve coordination and management of care and patient 
     adherence to recommendations made by their provider).
       ``(g) Report on Quality Measures.--As a condition for 
     receiving payment for health home services provided to an 
     eligible individual with chronic conditions, a designated 
     provider shall report to the State, in accordance with such 
     requirements as the Secretary shall specify, on all 
     applicable measures for determining the quality of such 
     services. When appropriate and feasible, a designated 
     provider shall use health information technology in providing 
     the State with such information.
       ``(h) Definitions.--In this section:
       ``(1) Eligible individual with chronic conditions.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `eligible individual with chronic conditions' means an 
     individual who--
       ``(i) is eligible for medical assistance under the State 
     plan or under a waiver of such plan; and
       ``(ii) has at least--

       ``(I) 2 chronic conditions;
       ``(II) 1 chronic condition and is at risk of having a 
     second chronic condition; or
       ``(III) 1 serious and persistent mental health condition.

       ``(B) Rule of construction.--Nothing in this paragraph 
     shall prevent the Secretary from establishing higher levels 
     as to the number or severity of chronic or mental health 
     conditions for purposes of determining eligibility for 
     receipt of health home services under this section.
       ``(2) Chronic condition.--The term `chronic condition' has 
     the meaning given that term by the Secretary and shall 
     include, but is not limited to, the following:
       ``(A) A mental health condition.
       ``(B) Substance use disorder.
       ``(C) Asthma.
       ``(D) Diabetes.
       ``(E) Heart disease.
       ``(F) Being overweight, as evidenced by having a Body Mass 
     Index (BMI) over 25.
       ``(3) Health home.--The term `health home' means a 
     designated provider (including a provider that operates in 
     coordination with a team

[[Page 4258]]

     of health care professionals) or a health team selected by an 
     eligible individual with chronic conditions to provide health 
     home services.
       ``(4) Health home services.--
       ``(A) In general.--The term `health home services' means 
     comprehensive and timely high-quality services described in 
     subparagraph (B) that are provided by a designated provider, 
     a team of health care professionals operating with such a 
     provider, or a health team.
       ``(B) Services described.--The services described in this 
     subparagraph are--
       ``(i) comprehensive care management;
       ``(ii) care coordination and health promotion;
       ``(iii) comprehensive transitional care, including 
     appropriate follow-up, from inpatient to other settings;
       ``(iv) patient and family support (including authorized 
     representatives);
       ``(v) referral to community and social support services, if 
     relevant; and
       ``(vi) use of health information technology to link 
     services, as feasible and appropriate.
       ``(5) Designated provider.--The term `designated provider' 
     means a physician, clinical practice or clinical group 
     practice, rural clinic, community health center, community 
     mental health center, home health agency, or any other entity 
     or provider (including pediatricians, gynecologists, and 
     obstetricians) that is determined by the State and approved 
     by the Secretary to be qualified to be a health home for 
     eligible individuals with chronic conditions on the basis of 
     documentation evidencing that the physician, practice, or 
     clinic--
       ``(A) has the systems and infrastructure in place to 
     provide health home services; and
       ``(B) satisfies the qualification standards established by 
     the Secretary under subsection (b).
       ``(6) Team of health care professionals.--The term `team of 
     health care professionals' means a team of health 
     professionals (as described in the State plan amendment) that 
     may--
       ``(A) include physicians and other professionals, such as a 
     nurse care coordinator, nutritionist, social worker, 
     behavioral health professional, or any professionals deemed 
     appropriate by the State; and
       ``(B) be free standing, virtual, or based at a hospital, 
     community health center, community mental health center, 
     rural clinic, clinical practice or clinical group practice, 
     academic health center, or any entity deemed appropriate by 
     the State and approved by the Secretary.
       ``(7) Health team.--The term `health team' has the meaning 
     given such term for purposes of section 3502 of the Patient 
     Protection and Affordable Care Act.''.
       (b) Evaluation.--
       (1) Independent evaluation.--
       (A) In general.--The Secretary shall enter into a contract 
     with an independent entity or organization to conduct an 
     evaluation and assessment of the States that have elected the 
     option to provide coordinated care through a health home for 
     Medicaid beneficiaries with chronic conditions under section 
     1945 of the Social Security Act (as added by subsection (a)) 
     for the purpose of determining the effect of such option on 
     reducing hospital admissions, emergency room visits, and 
     admissions to skilled nursing facilities.
       (B) Evaluation report.--Not later than January 1, 2017, the 
     Secretary shall report to Congress on the evaluation and 
     assessment conducted under subparagraph (A).
       (2) Survey and interim report.--
       (A) In general.--Not later than January 1, 2014, the 
     Secretary of Health and Human Services shall survey States 
     that have elected the option under section 1945 of the Social 
     Security Act (as added by subsection (a)) and report to 
     Congress on the nature, extent, and use of such option, 
     particularly as it pertains to--
       (i) hospital admission rates;
       (ii) chronic disease management;
       (iii) coordination of care for individuals with chronic 
     conditions;
       (iv) assessment of program implementation;
       (v) processes and lessons learned (as described in 
     subparagraph (B));
       (vi) assessment of quality improvements and clinical 
     outcomes under such option; and
       (vii) estimates of cost savings.
       (B)  Implementation reporting.--A State that has elected 
     the option under section 1945 of the Social Security Act (as 
     added by subsection (a)) shall report to the Secretary, as 
     necessary, on processes that have been developed and lessons 
     learned regarding provision of coordinated care through a 
     health home for Medicaid beneficiaries with chronic 
     conditions under such option.

     SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE 
                   AROUND A HOSPITALIZATION.

       (a) Authority To Conduct Project.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish a demonstration project under title XIX of the 
     Social Security Act to evaluate the use of bundled payments 
     for the provision of integrated care for a Medicaid 
     beneficiary--
       (A) with respect to an episode of care that includes a 
     hospitalization; and
       (B) for concurrent physicians services provided during a 
     hospitalization.
       (2) Duration.--The demonstration project shall begin on 
     January 1, 2012, and shall end on December 31, 2016.
       (b) Requirements.--The demonstration project shall be 
     conducted in accordance with the following:
       (1) The demonstration project shall be conducted in up to 8 
     States, determined by the Secretary based on consideration of 
     the potential to lower costs under the Medicaid program while 
     improving care for Medicaid beneficiaries. A State selected 
     to participate in the demonstration project may target the 
     demonstration project to particular categories of 
     beneficiaries, beneficiaries with particular diagnoses, or 
     particular geographic regions of the State, but the Secretary 
     shall insure that, as a whole, the demonstration project is, 
     to the greatest extent possible, representative of the 
     demographic and geographic composition of Medicaid 
     beneficiaries nationally.
       (2) The demonstration project shall focus on conditions 
     where there is evidence of an opportunity for providers of 
     services and suppliers to improve the quality of care 
     furnished to Medicaid beneficiaries while reducing total 
     expenditures under the State Medicaid programs selected to 
     participate, as determined by the Secretary.
       (3) A State selected to participate in the demonstration 
     project shall specify the 1 or more episodes of care the 
     State proposes to address in the project, the services to be 
     included in the bundled payments, and the rationale for the 
     selection of such episodes of care and services. The 
     Secretary may modify the episodes of care as well as the 
     services to be included in the bundled payments prior to or 
     after approving the project. The Secretary may also vary such 
     factors among the different States participating in the 
     demonstration project.
       (4) The Secretary shall ensure that payments made under the 
     demonstration project are adjusted for severity of illness 
     and other characteristics of Medicaid beneficiaries within a 
     category or having a diagnosis targeted as part of the 
     demonstration project. States shall ensure that Medicaid 
     beneficiaries are not liable for any additional cost sharing 
     than if their care had not been subject to payment under the 
     demonstration project.
       (5) Hospitals participating in the demonstration project 
     shall have or establish robust discharge planning programs to 
     ensure that Medicaid beneficiaries requiring post-acute care 
     are appropriately placed in, or have ready access to, post-
     acute care settings.
       (6) The Secretary and each State selected to participate in 
     the demonstration project shall ensure that the demonstration 
     project does not result in the Medicaid beneficiaries whose 
     care is subject to payment under the demonstration project 
     being provided with less items and services for which medical 
     assistance is provided under the State Medicaid program than 
     the items and services for which medical assistance would 
     have been provided to such beneficiaries under the State 
     Medicaid program in the absence of the demonstration project.
       (c) Waiver of Provisions.--Notwithstanding section 1115(a) 
     of the Social Security Act (42 U.S.C. 1315(a)), the Secretary 
     may waive such provisions of titles XIX, XVIII, and XI of 
     that Act as may be necessary to accomplish the goals of the 
     demonstration, ensure beneficiary access to acute and post-
     acute care, and maintain quality of care.
       (d) Evaluation and Report.--
       (1) Data.--Each State selected to participate in the 
     demonstration project under this section shall provide to the 
     Secretary, in such form and manner as the Secretary shall 
     specify, relevant data necessary to monitor outcomes, costs, 
     and quality, and evaluate the rationales for selection of the 
     episodes of care and services specified by States under 
     subsection (b)(3).
       (2) Report.--Not later than 1 year after the conclusion of 
     the demonstration project, the Secretary shall submit a 
     report to Congress on the results of the demonstration 
     project.

     SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION 
                   PROJECT.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall, in 
     coordination with the Center for Medicare and Medicaid 
     Innovation (as established under section 1115A of the Social 
     Security Act, as added by section 3021 of this Act), 
     establish the Medicaid Global Payment System Demonstration 
     Project under which a participating State shall adjust the 
     payments made to an eligible safety net hospital system or 
     network from a fee-for-service payment structure to a global 
     capitated payment model.
       (b) Duration and Scope.--The demonstration project 
     conducted under this section shall operate during a period of 
     fiscal years 2010 through 2012. The Secretary shall select 
     not more than 5 States to participate in the demonstration 
     project.
       (c) Eligible Safety Net Hospital System or Network.--For 
     purposes of this section, the term ``eligible safety net 
     hospital system or network'' means a large, safety net 
     hospital system or network (as defined by the Secretary) that 
     operates within a State selected by the Secretary under 
     subsection (b).
       (d) Evaluation.--
       (1) Testing.--The Innovation Center shall test and evaluate 
     the demonstration project conducted under this section to 
     examine any changes in health care quality outcomes and 
     spending by the eligible safety net hospital systems or 
     networks.
       (2) Budget neutrality.--During the testing period under 
     paragraph (1), any budget neutrality requirements under 
     section 1115A(b)(3) of the Social Security Act (as so added) 
     shall not be applicable.
       (3) Modification.--During the testing period under 
     paragraph (1), the Secretary may, in the Secretary's 
     discretion, modify or terminate the demonstration project 
     conducted under this section.
       (e) Report.--Not later than 12 months after the date of 
     completion of the demonstration

[[Page 4259]]

     project under this section, the Secretary shall submit to 
     Congress a report containing the results of the evaluation 
     and testing conducted under subsection (d), together with 
     recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.
       (f) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as are necessary to carry out 
     this section.

     SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION 
                   DEMONSTRATION PROJECT.

       (a) Authority To Conduct Demonstration.--
       (1) In general.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     establish the Pediatric Accountable Care Organization 
     Demonstration Project to authorize a participating State to 
     allow pediatric medical providers that meet specified 
     requirements to be recognized as an accountable care 
     organization for purposes of receiving incentive payments (as 
     described under subsection (d)), in the same manner as an 
     accountable care organization is recognized and provided with 
     incentive payments under section 1899 of the Social Security 
     Act (as added by section 3022).
       (2) Duration.--The demonstration project shall begin on 
     January 1, 2012, and shall end on December 31, 2016.
       (b) Application.--A State that desires to participate in 
     the demonstration project under this section shall submit to 
     the Secretary an application at such time, in such manner, 
     and containing such information as the Secretary may require.
       (c) Requirements.--
       (1) Performance guidelines.--The Secretary, in consultation 
     with the States and pediatric providers, shall establish 
     guidelines to ensure that the quality of care delivered to 
     individuals by a provider recognized as an accountable care 
     organization under this section is not less than the quality 
     of care that would have otherwise been provided to such 
     individuals.
       (2) Savings requirement.--A participating State, in 
     consultation with the Secretary, shall establish an annual 
     minimal level of savings in expenditures for items and 
     services covered under the Medicaid program under title XIX 
     of the Social Security Act and the CHIP program under title 
     XXI of such Act that must be reached by an accountable care 
     organization in order for such organization to receive an 
     incentive payment under subsection (d).
       (3) Minimum participation period.--A provider desiring to 
     be recognized as an accountable care organization under the 
     demonstration project shall enter into an agreement with the 
     State to participate in the project for not less than a 3-
     year period.
       (d) Incentive Payment.--An accountable care organization 
     that meets the performance guidelines established by the 
     Secretary under subsection (c)(1) and achieves savings 
     greater than the annual minimal savings level established by 
     the State under subsection (c)(2) shall receive an incentive 
     payment for such year equal to a portion (as determined 
     appropriate by the Secretary) of the amount of such excess 
     savings. The Secretary may establish an annual cap on 
     incentive payments for an accountable care organization.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as are necessary to carry out 
     this section.

     SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION 
                   PROJECT.

       (a) Authority To Conduct Demonstration Project.--The 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall establish a 
     demonstration project under which an eligible State (as 
     described in subsection (c)) shall provide payment under the 
     State Medicaid plan under title XIX of the Social Security 
     Act to an institution for mental diseases that is not 
     publicly owned or operated and that is subject to the 
     requirements of section 1867 of the Social Security Act (42 
     U.S.C. 1395dd) for the provision of medical assistance 
     available under such plan to individuals who--
       (1) have attained age 21, but have not attained age 65;
       (2) are eligible for medical assistance under such plan; 
     and
       (3) require such medical assistance to stabilize an 
     emergency medical condition.
       (b) Stabilization Review.--A State shall specify in its 
     application described in subsection (c)(1) establish a 
     mechanism for how it will ensure that institutions 
     participating in the demonstration will determine whether or 
     not such individuals have been stabilized (as defined in 
     subsection (h)(5)). This mechanism shall commence before the 
     third day of the inpatient stay. States participating in the 
     demonstration project may manage the provision of services 
     for the stabilization of medical emergency conditions through 
     utilization review, authorization, or management practices, 
     or the application of medical necessity and appropriateness 
     criteria applicable to behavioral health.
       (c) Eligible State Defined.--
       (1) In general.--An eligible State is a State that has made 
     an application and has been selected pursuant to paragraphs 
     (2) and (3).
       (2) Application.--A State seeking to participate in the 
     demonstration project under this section shall submit to the 
     Secretary, at such time and in such format as the Secretary 
     requires, an application that includes such information, 
     provisions, and assurances, as the Secretary may require.
       (3) Selection.--A State shall be determined eligible for 
     the demonstration by the Secretary on a competitive basis 
     among States with applications meeting the requirements of 
     paragraph (1). In selecting State applications for the 
     demonstration project, the Secretary shall seek to achieve an 
     appropriate national balance in the geographic distribution 
     of such projects.
       (d) Length of Demonstration Project.--The demonstration 
     project established under this section shall be conducted for 
     a period of 3 consecutive years.
       (e) Limitations on Federal Funding.--
       (1) Appropriation.--
       (A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to carry out 
     this section, $75,000,000 for fiscal year 2011.
       (B) Budget authority.--Subparagraph (A) constitutes budget 
     authority in advance of appropriations Act and represents the 
     obligation of the Federal Government to provide for the 
     payment of the amounts appropriated under that subparagraph.
       (2) 5-year availability.--Funds appropriated under 
     paragraph (1) shall remain available for obligation through 
     December 31, 2015.
       (3) Limitation on payments.--In no case may--
       (A) the aggregate amount of payments made by the Secretary 
     to eligible States under this section exceed $75,000,000; or
       (B) payments be provided by the Secretary under this 
     section after December 31, 2015.
       (4) Funds allocated to states.--Funds shall be allocated to 
     eligible States on the basis of criteria, including a State's 
     application and the availability of funds, as determined by 
     the Secretary.
       (5) Payments to states.--The Secretary shall pay to each 
     eligible State, from its allocation under paragraph (4), an 
     amount each quarter equal to the Federal medical assistance 
     percentage of expenditures in the quarter for medical 
     assistance described in subsection (a). As a condition of 
     receiving payment, a State shall collect and report 
     information, as determined necessary by the Secretary, for 
     the purposes of providing Federal oversight and conducting an 
     evaluation under subsection (f)(1).
       (f) Evaluation and Report to Congress.--
       (1) Evaluation.--The Secretary shall conduct an evaluation 
     of the demonstration project in order to determine the impact 
     on the functioning of the health and mental health service 
     system and on individuals enrolled in the Medicaid program 
     and shall include the following:
       (A) An assessment of access to inpatient mental health 
     services under the Medicaid program; average lengths of 
     inpatient stays; and emergency room visits.
       (B) An assessment of discharge planning by participating 
     hospitals.
       (C) An assessment of the impact of the demonstration 
     project on the costs of the full range of mental health 
     services (including inpatient, emergency and ambulatory 
     care).
       (D) An analysis of the percentage of consumers with 
     Medicaid coverage who are admitted to inpatient facilities as 
     a result of the demonstration project as compared to those 
     admitted to these same facilities through other means.
       (E) A recommendation regarding whether the demonstration 
     project should be continued after December 31, 2013, and 
     expanded on a national basis.
       (2) Report.--Not later than December 31, 2013, the 
     Secretary shall submit to Congress and make available to the 
     public a report on the findings of the evaluation under 
     paragraph (1).
       (g) Waiver Authority.--
       (1) In general.--The Secretary shall waive the limitation 
     of subdivision (B) following paragraph (28) of section 
     1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
     (relating to limitations on payments for care or services for 
     individuals under 65 years of age who are patients in an 
     institution for mental diseases) for purposes of carrying out 
     the demonstration project under this section.
       (2) Limited other waiver authority.--The Secretary may 
     waive other requirements of titles XI and XIX of the Social 
     Security Act (including the requirements of sections 
     1902(a)(1) (relating to statewideness) and 1902(1)(10)(B) 
     (relating to comparability)) only to extent necessary to 
     carry out the demonstration project under this section.
       (h) Definitions.--In this section:
       (1) Emergency medical condition.--The term ``emergency 
     medical condition'' means, with respect to an individual, an 
     individual who expresses suicidal or homicidal thoughts or 
     gestures, if determined dangerous to self or others.
       (2) Federal medical assistance percentage.--The term 
     ``Federal medical assistance percentage'' has the meaning 
     given that term with respect to a State under section 1905(b) 
     of the Social Security Act (42 U.S.C. 1396d(b)).
       (3) Institution for mental diseases.--The term 
     ``institution for mental diseases'' has the meaning given to 
     that term in section 1905(i) of the Social Security Act (42 
     U.S.C. 1396d(i)).
       (4) Medical assistance.--The term ``medical assistance'' 
     has the meaning given that term in section 1905(a) of the 
     Social Security Act (42 U.S.C. 1396d(a)).
       (5) Stabilized.--The term ``stabilized'' means, with 
     respect to an individual, that the emergency medical 
     condition no longer exists with respect to the individual and 
     the individual is no longer dangerous to self or others.
       (6) State.--The term ``State'' has the meaning given that 
     term for purposes of title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).

[[Page 4260]]



 Subtitle J--Improvements to the Medicaid and CHIP Payment and Access 
                          Commission (MACPAC)

     SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL 
                   MEDICAID BENEFICIARIES.

       (a) In General.--Section 1900 of the Social Security Act 
     (42 U.S.C. 1396) is amended--
       (1) in subsection (b)--
       (A) in paragraph (1)--
       (i) in the paragraph heading, by inserting ``for all 
     states'' before ``and annual''; and
       (ii) in subparagraph (A), by striking ``children's'';
       (iii) in subparagraph (B), by inserting ``, the Secretary, 
     and States'' after ``Congress'';
       (iv) in subparagraph (C), by striking ``March 1'' and 
     inserting ``March 15''; and
       (v) in subparagraph (D), by striking ``June 1'' and 
     inserting ``June 15'';
       (B) in paragraph (2)--
       (i) in subparagraph (A)--

       (I) in clause (i)--

       (aa) by inserting ``the efficient provision of'' after 
     ``expenditures for''; and
       (bb) by striking ``hospital, skilled nursing facility, 
     physician, Federally-qualified health center, rural health 
     center, and other fees'' and inserting ``payments to medical, 
     dental, and health professionals, hospitals, residential and 
     long-term care providers, providers of home and community 
     based services, Federally-qualified health centers and rural 
     health clinics, managed care entities, and providers of other 
     covered items and services''; and

       (II) in clause (iii), by inserting ``(including how such 
     factors and methodologies enable such beneficiaries to obtain 
     the services for which they are eligible, affect provider 
     supply, and affect providers that serve a disproportionate 
     share of low-income and other vulnerable populations)'' after 
     ``beneficiaries'';

       (ii) by redesignating subparagraphs (B) and (C) as 
     subparagraphs (F) and (H), respectively;
       (iii) by inserting after subparagraph (A), the following:
       ``(B) Eligibility policies.--Medicaid and CHIP eligibility 
     policies, including a determination of the degree to which 
     Federal and State policies provide health care coverage to 
     needy populations.
       ``(C) Enrollment and retention processes.--Medicaid and 
     CHIP enrollment and retention processes, including a 
     determination of the degree to which Federal and State 
     policies encourage the enrollment of individuals who are 
     eligible for such programs and screen out individuals who are 
     ineligible, while minimizing the share of program expenses 
     devoted to such processes.
       ``(D) Coverage policies.--Medicaid and CHIP benefit and 
     coverage policies, including a determination of the degree to 
     which Federal and State policies provide access to the 
     services enrollees require to improve and maintain their 
     health and functional status.
       ``(E) Quality of care.--Medicaid and CHIP policies as they 
     relate to the quality of care provided under those programs, 
     including a determination of the degree to which Federal and 
     State policies achieve their stated goals and interact with 
     similar goals established by other purchasers of health care 
     services.'';
       (iv) by inserting after subparagraph (F) (as redesignated 
     by clause (ii) of this subparagraph), the following:
       ``(G) Interactions with medicare and medicaid.--Consistent 
     with paragraph (11), the interaction of policies under 
     Medicaid and the Medicare program under title XVIII, 
     including with respect to how such interactions affect access 
     to services, payments, and dual eligible individuals.'' and
       (v) in subparagraph (H) (as so redesignated), by inserting 
     ``and preventive, acute, and long-term services and 
     supports'' after ``barriers'';
       (C) by redesignating paragraphs (3) through (9) as 
     paragraphs (4) through (10), respectively;
       (D) by inserting after paragraph (2), the following new 
     paragraph:
       ``(3) Recommendations and reports of state-specific data.--
     MACPAC shall--
       ``(A) review national and State-specific Medicaid and CHIP 
     data; and
       ``(B) submit reports and recommendations to Congress, the 
     Secretary, and States based on such reviews.'';
       (E) in paragraph (4), as redesignated by subparagraph (C), 
     by striking ``or any other problems'' and all that follows 
     through the period and inserting ``, as well as other factors 
     that adversely affect, or have the potential to adversely 
     affect, access to care by, or the health care status of, 
     Medicaid and CHIP beneficiaries. MACPAC shall include in the 
     annual report required under paragraph (1)(D) a description 
     of all such areas or problems identified with respect to the 
     period addressed in the report.'';
       (F) in paragraph (5), as so redesignated,--
       (i) in the paragraph heading, by inserting ``and 
     regulations'' after ``reports''; and
       (ii) by striking ``If'' and inserting the following:
       ``(A) Certain secretarial reports.--If''; and
       (iii) in the second sentence, by inserting ``and the 
     Secretary'' after ``appropriate committees of Congress''; and
       (iv) by adding at the end the following:
       ``(B) Regulations.--MACPAC shall review Medicaid and CHIP 
     regulations and may comment through submission of a report to 
     the appropriate committees of Congress and the Secretary, on 
     any such regulations that affect access, quality, or 
     efficiency of health care.'';
       (G) in paragraph (10), as so redesignated, by inserting ``, 
     and shall submit with any recommendations, a report on the 
     Federal and State-specific budget consequences of the 
     recommendations'' before the period; and
       (H) by adding at the end the following:
       ``(11) Consultation and coordination with medpac.--
       ``(A) In general.--MACPAC shall consult with the Medicare 
     Payment Advisory Commission (in this paragraph referred to as 
     `MedPAC') established under section 1805 in carrying out its 
     duties under this section, as appropriate and particularly 
     with respect to the issues specified in paragraph (2) as they 
     relate to those Medicaid beneficiaries who are dually 
     eligible for Medicaid and the Medicare program under title 
     XVIII, adult Medicaid beneficiaries (who are not dually 
     eligible for Medicare), and beneficiaries under Medicare. 
     Responsibility for analysis of and recommendations to change 
     Medicare policy regarding Medicare beneficiaries, including 
     Medicare beneficiaries who are dually eligible for Medicare 
     and Medicaid, shall rest with MedPAC.
       ``(B) Information sharing.--MACPAC and MedPAC shall have 
     access to deliberations and records of the other such entity, 
     respectively, upon the request of the other such entity.
       ``(12) Consultation with states.--MACPAC shall regularly 
     consult with States in carrying out its duties under this 
     section, including with respect to developing processes for 
     carrying out such duties, and shall ensure that input from 
     States is taken into account and represented in MACPAC's 
     recommendations and reports.
       ``(13) Coordinate and consult with the federal coordinated 
     health care office.--MACPAC shall coordinate and consult with 
     the Federal Coordinated Health Care Office established under 
     section 2081 of the Patient Protection and Affordable Care 
     Act before making any recommendations regarding dual eligible 
     individuals.
       ``(14) Programmatic oversight vested in the secretary.--
     MACPAC's authority to make recommendations in accordance with 
     this section shall not affect, or be considered to duplicate, 
     the Secretary's authority to carry out Federal 
     responsibilities with respect to Medicaid and CHIP.'';
       (2) in subsection (c)(2)--
       (A) by striking subparagraphs (A) and (B) and inserting the 
     following:
       ``(A) In general.--The membership of MACPAC shall include 
     individuals who have had direct experience as enrollees or 
     parents or caregivers of enrollees in Medicaid or CHIP and 
     individuals with national recognition for their expertise in 
     Federal safety net health programs, health finance and 
     economics, actuarial science, health plans and integrated 
     delivery systems, reimbursement for health care, health 
     information technology, and other providers of health 
     services, public health, and other related fields, who 
     provide a mix of different professions, broad geographic 
     representation, and a balance between urban and rural 
     representation.
       ``(B) Inclusion.--The membership of MACPAC shall include 
     (but not be limited to) physicians, dentists, and other 
     health professionals, employers, third-party payers, and 
     individuals with expertise in the delivery of health 
     services. Such membership shall also include representatives 
     of children, pregnant women, the elderly, individuals with 
     disabilities, caregivers, and dual eligible individuals, 
     current or former representatives of State agencies 
     responsible for administering Medicaid, and current or former 
     representatives of State agencies responsible for 
     administering CHIP.''.
       (3) in subsection (d)(2), by inserting ``and State'' after 
     ``Federal'';
       (4) in subsection (e)(1), in the first sentence, by 
     inserting ``and, as a condition for receiving payments under 
     sections 1903(a) and 2105(a), from any State agency 
     responsible for administering Medicaid or CHIP,'' after 
     ``United States''; and
       (5) in subsection (f)--
       (A) in the subsection heading, by striking ``Authorization 
     of Appropriations'' and inserting ``Funding'';
       (B) in paragraph (1), by inserting ``(other than for fiscal 
     year 2010)'' before ``in the same manner''; and
       (C) by adding at the end the following:
       ``(3) Funding for fiscal year 2010.--
       ``(A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to MACPAC to 
     carry out the provisions of this section for fiscal year 
     2010, $9,000,000.
       ``(B) Transfer of funds.--Notwithstanding section 
     2104(a)(13), from the amounts appropriated in such section 
     for fiscal year 2010, $2,000,000 is hereby transferred and 
     made available in such fiscal year to MACPAC to carry out the 
     provisions of this section.
       ``(4) Availability.--Amounts made available under 
     paragraphs (2) and (3) to MACPAC to carry out the provisions 
     of this section shall remain available until expended.''.
       (b) Conforming MedPAC Amendments.--Section 1805(b) of the 
     Social Security Act (42 U.S.C. 1395b-6(b)), is amended--
       (1) in paragraph (1)(C), by striking ``March 1 of each year 
     (beginning with 1998)'' and inserting ``March 15'';
       (2) in paragraph (1)(D), by inserting ``, and (beginning 
     with 2012) containing an examination of the topics described 
     in paragraph (9), to the extent feasible'' before the period; 
     and
       (3) by adding at the end the following:
       ``(9) Review and annual report on medicaid and commercial 
     trends.--The Commission shall review and report on aggregate 
     trends in spending, utilization, and financial performance 
     under the Medicaid program under title XIX and the private 
     market for health care services

[[Page 4261]]

     with respect to providers for which, on an aggregate national 
     basis, a significant portion of revenue or services is 
     associated with the Medicaid program. Where appropriate, the 
     Commission shall conduct such review in consultation with the 
     Medicaid and CHIP Payment and Access Commission established 
     under section 1900 (in this section referred to as `MACPAC').
       ``(10) Coordinate and consult with the federal coordinated 
     health care office.--The Commission shall coordinate and 
     consult with the Federal Coordinated Health Care Office 
     established under section 2081 of the Patient Protection and 
     Affordable Care Act before making any recommendations 
     regarding dual eligible individuals.
       ``(11) Interaction of medicaid and medicare.--The 
     Commission shall consult with MACPAC in carrying out its 
     duties under this section, as appropriate. Responsibility for 
     analysis of and recommendations to change Medicare policy 
     regarding Medicare beneficiaries, including Medicare 
     beneficiaries who are dually eligible for Medicare and 
     Medicaid, shall rest with the Commission. Responsibility for 
     analysis of and recommendations to change Medicaid policy 
     regarding Medicaid beneficiaries, including Medicaid 
     beneficiaries who are dually eligible for Medicare and 
     Medicaid, shall rest with MACPAC.''.

    Subtitle K--Protections for American Indians and Alaska Natives

     SEC. 2901. SPECIAL RULES RELATING TO INDIANS.

       (a) No Cost-sharing for Indians With Income at or Below 300 
     Percent of Poverty Enrolled in Coverage Through a State 
     Exchange.--For provisions prohibiting cost sharing for 
     Indians enrolled in any qualified health plan in the 
     individual market through an Exchange, see section 1402(d) of 
     the Patient Protection and Affordable Care Act.
       (b) Payer of Last Resort.--Health programs operated by the 
     Indian Health Service, Indian tribes, tribal organizations, 
     and Urban Indian organizations (as those terms are defined in 
     section 4 of the Indian Health Care Improvement Act (25 
     U.S.C. 1603)) shall be the payer of last resort for services 
     provided by such Service, tribes, or organizations to 
     individuals eligible for services through such programs, 
     notwithstanding any Federal, State, or local law to the 
     contrary.
       (c) Facilitating Enrollment of Indians Under the Express 
     Lane Option.--Section 1902(e)(13)(F)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(e)(13)(F)(ii)) is amended--
       (1) in the clause heading, by inserting ``and indian tribes 
     and tribal organizations'' after ``agencies''; and
       (2) by adding at the end the following:

       ``(IV) The Indian Health Service, an Indian Tribe, Tribal 
     Organization, or Urban Indian Organization (as defined in 
     section 1139(c)).''.

       (d) Technical Corrections.--Section 1139(c) of the Social 
     Security Act (42 U.S.C. 1320b-9(c)) is amended by striking 
     ``In this section'' and inserting ``For purposes of this 
     section, title XIX, and title XXI''.

     SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL 
                   MEDICARE PART B SERVICES FURNISHED BY CERTAIN 
                   INDIAN HOSPITALS AND CLINICS.

       (a) Reimbursement for All Medicare Part B Services 
     Furnished by Certain Indian Hospitals and Clinics.--Section 
     1880(e)(1)(A) of the Social Security Act (42 U.S.C. 
     1395qq(e)(1)(A)) is amended by striking ``during the 5-year 
     period beginning on'' and inserting ``on or after''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to items or services furnished on or after 
     January 1, 2010.

             Subtitle L--Maternal and Child Health Services

     SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME 
                   VISITING PROGRAMS.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
     is amended by adding at the end the following new section:

     ``SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME 
                   VISITING PROGRAMS.

       ``(a) Purposes.--The purposes of this section are--
       ``(1) to strengthen and improve the programs and activities 
     carried out under this title;
       ``(2) to improve coordination of services for at risk 
     communities; and
       ``(3) to identify and provide comprehensive services to 
     improve outcomes for families who reside in at risk 
     communities.
       ``(b) Requirement for All States To Assess Statewide Needs 
     and Identify at Risk Communities.--
       ``(1) In general.--Not later than 6 months after the date 
     of enactment of this section, each State shall, as a 
     condition of receiving payments from an allotment for the 
     State under section 502 for fiscal year 2011, conduct a 
     statewide needs assessment (which shall be separate from the 
     statewide needs assessment required under section 505(a)) 
     that identifies--
       ``(A) communities with concentrations of--
       ``(i) premature birth, low-birth weight infants, and infant 
     mortality, including infant death due to neglect, or other 
     indicators of at-risk prenatal, maternal, newborn, or child 
     health;
       ``(ii) poverty;
       ``(iii) crime;
       ``(iv) domestic violence;
       ``(v) high rates of high-school drop-outs;
       ``(vi) substance abuse;
       ``(vii) unemployment; or
       ``(viii) child maltreatment;
       ``(B) the quality and capacity of existing programs or 
     initiatives for early childhood home visitation in the State 
     including--
       ``(i) the number and types of individuals and families who 
     are receiving services under such programs or initiatives;
       ``(ii) the gaps in early childhood home visitation in the 
     State; and
       ``(iii) the extent to which such programs or initiatives 
     are meeting the needs of eligible families described in 
     subsection (k)(2); and
       ``(C) the State's capacity for providing substance abuse 
     treatment and counseling services to individuals and families 
     in need of such treatment or services.
       ``(2) Coordination with other assessments.--In conducting 
     the statewide needs assessment required under paragraph (1), 
     the State shall coordinate with, and take into account, other 
     appropriate needs assessments conducted by the State, as 
     determined by the Secretary, including the needs assessment 
     required under section 505(a) (both the most recently 
     completed assessment and any such assessment in progress), 
     the communitywide strategic planning and needs assessments 
     conducted in accordance with section 640(g)(1)(C) of the Head 
     Start Act, and the inventory of current unmet needs and 
     current community-based and prevention-focused programs and 
     activities to prevent child abuse and neglect, and other 
     family resource services operating in the State required 
     under section 205(3) of the Child Abuse Prevention and 
     Treatment Act.
       ``(3) Submission to the secretary.--Each State shall submit 
     to the Secretary, in such form and manner as the Secretary 
     shall require--
       ``(A) the results of the statewide needs assessment 
     required under paragraph (1); and
       ``(B) a description of how the State intends to address 
     needs identified by the assessment, particularly with respect 
     to communities identified under paragraph (1)(A), which may 
     include applying for a grant to conduct an early childhood 
     home visitation program in accordance with the requirements 
     of this section.
       ``(c) Grants for Early Childhood Home Visitation 
     Programs.--
       ``(1) Authority to make grants.--In addition to any other 
     payments made under this title to a State, the Secretary 
     shall make grants to eligible entities to enable the entities 
     to deliver services under early childhood home visitation 
     programs that satisfy the requirements of subsection (d) to 
     eligible families in order to promote improvements in 
     maternal and prenatal health, infant health, child health and 
     development, parenting related to child development outcomes, 
     school readiness, and the socioeconomic status of such 
     families, and reductions in child abuse, neglect, and 
     injuries.
       ``(2) Authority to use initial grant funds for planning or 
     implementation.--An eligible entity that receives a grant 
     under paragraph (1) may use a portion of the funds made 
     available to the entity during the first 6 months of the 
     period for which the grant is made for planning or 
     implementation activities to assist with the establishment of 
     early childhood home visitation programs that satisfy the 
     requirements of subsection (d).
       ``(3) Grant duration.--The Secretary shall determine the 
     period of years for which a grant is made to an eligible 
     entity under paragraph (1).
       ``(4) Technical assistance.--The Secretary shall provide an 
     eligible entity that receives a grant under paragraph (1) 
     with technical assistance in administering programs or 
     activities conducted in whole or in part with grant funds.
       ``(d) Requirements.--The requirements of this subsection 
     for an early childhood home visitation program conducted with 
     a grant made under this section are as follows:
       ``(1) Quantifiable, measurable improvement in benchmark 
     areas.--
       ``(A) In general.--The eligible entity establishes, subject 
     to the approval of the Secretary, quantifiable, measurable 3- 
     and 5-year benchmarks for demonstrating that the program 
     results in improvements for the eligible families 
     participating in the program in each of the following areas:
       ``(i) Improved maternal and newborn health.
       ``(ii) Prevention of child injuries, child abuse, neglect, 
     or maltreatment, and reduction of emergency department 
     visits.
       ``(iii) Improvement in school readiness and achievement.
       ``(iv) Reduction in crime or domestic violence.
       ``(v) Improvements in family economic self-sufficiency.
       ``(vi) Improvements in the coordination and referrals for 
     other community resources and supports.
       ``(B) Demonstration of improvements after 3 years.--
       ``(i) Report to the secretary.--Not later than 30 days 
     after the end of the 3rd year in which the eligible entity 
     conducts the program, the entity submits to the Secretary a 
     report demonstrating improvement in at least 4 of the areas 
     specified in subparagraph (A).
       ``(ii) Corrective action plan.--If the report submitted by 
     the eligible entity under clause (i) fails to demonstrate 
     improvement in at least 4 of the areas specified in 
     subparagraph (A), the entity shall develop and implement a 
     plan to improve outcomes in each of the areas specified in 
     subparagraph (A), subject to approval by the Secretary. The 
     plan shall include provisions for the Secretary to monitor 
     implementation of the plan and conduct continued oversight of 
     the program, including through submission by the entity of 
     regular reports to the Secretary.

[[Page 4262]]

       ``(iii) Technical assistance.--

       ``(I) In general.--The Secretary shall provide an eligible 
     entity required to develop and implement an improvement plan 
     under clause (ii) with technical assistance to develop and 
     implement the plan. The Secretary may provide the technical 
     assistance directly or through grants, contracts, or 
     cooperative agreements.
       ``(II) Advisory panel.--The Secretary shall establish an 
     advisory panel for purposes of obtaining recommendations 
     regarding the technical assistance provided to entities in 
     accordance with subclause (I).

       ``(iv) No improvement or failure to submit report.--If the 
     Secretary determines after a period of time specified by the 
     Secretary that an eligible entity implementing an improvement 
     plan under clause (ii) has failed to demonstrate any 
     improvement in the areas specified in subparagraph (A), or if 
     the Secretary determines that an eligible entity has failed 
     to submit the report required under clause (i), the Secretary 
     shall terminate the entity's grant and may include any 
     unexpended grant funds in grants made to nonprofit 
     organizations under subsection (h)(2)(B).
       ``(C) Final report.--Not later than December 31, 2015, the 
     eligible entity shall submit a report to the Secretary 
     demonstrating improvements (if any) in each of the areas 
     specified in subparagraph (A).
       ``(2) Improvements in outcomes for individual families.--
       ``(A) In general.--The program is designed, with respect to 
     an eligible family participating in the program, to result in 
     the participant outcomes described in subparagraph (B) that 
     the eligible entity identifies on the basis of an 
     individualized assessment of the family, are relevant for 
     that family.
       ``(B) Participant outcomes.--The participant outcomes 
     described in this subparagraph are the following:
       ``(i) Improvements in prenatal, maternal, and newborn 
     health, including improved pregnancy outcomes
       ``(ii) Improvements in child health and development, 
     including the prevention of child injuries and maltreatment 
     and improvements in cognitive, language, social-emotional, 
     and physical developmental indicators.
       ``(iii) Improvements in parenting skills.
       ``(iv) Improvements in school readiness and child academic 
     achievement.
       ``(v) Reductions in crime or domestic violence.
       ``(vi) Improvements in family economic self-sufficiency.
       ``(vii) Improvements in the coordination of referrals for, 
     and the provision of, other community resources and supports 
     for eligible families, consistent with State child welfare 
     agency training.
       ``(3) Core components.--The program includes the following 
     core components:
       ``(A) Service delivery model or models.--
       ``(i) In general.--Subject to clause (ii), the program is 
     conducted using 1 or more of the service delivery models 
     described in item (aa) or (bb) of subclause (I) or in 
     subclause (II) selected by the eligible entity:

       ``(I) The model conforms to a clear consistent home 
     visitation model that has been in existence for at least 3 
     years and is research-based, grounded in relevant 
     empirically-based knowledge, linked to program determined 
     outcomes, associated with a national organization or 
     institution of higher education that has comprehensive home 
     visitation program standards that ensure high quality service 
     delivery and continuous program quality improvement, and has 
     demonstrated significant, (and in the case of the service 
     delivery model described in item (aa), sustained) positive 
     outcomes, as described in the benchmark areas specified in 
     paragraph (1)(A) and the participant outcomes described in 
     paragraph (2)(B), when evaluated using well-designed and 
     rigorous--

       ``(aa) randomized controlled research designs, and the 
     evaluation results have been published in a peer-reviewed 
     journal; or
       ``(bb) quasi-experimental research designs.

       ``(II) The model conforms to a promising and new approach 
     to achieving the benchmark areas specified in paragraph 
     (1)(A) and the participant outcomes described in paragraph 
     (2)(B), has been developed or identified by a national 
     organization or institution of higher education, and will be 
     evaluated through well-designed and rigorous process.

       ``(ii) Majority of grant funds used for evidence-based 
     models.--An eligible entity shall use not more than 25 
     percent of the amount of the grant paid to the entity for a 
     fiscal year for purposes of conducting a program using the 
     service delivery model described in clause (i)(II).
       ``(iii) Criteria for evidence of effectiveness of models.--
     The Secretary shall establish criteria for evidence of 
     effectiveness of the service delivery models and shall ensure 
     that the process for establishing the criteria is transparent 
     and provides the opportunity for public comment.
       ``(B) Additional requirements.--
       ``(i) The program adheres to a clear, consistent model that 
     satisfies the requirements of being grounded in empirically-
     based knowledge related to home visiting and linked to the 
     benchmark areas specified in paragraph (1)(A) and the 
     participant outcomes described in paragraph (2)(B) related to 
     the purposes of the program.
       ``(ii) The program employs well-trained and competent 
     staff, as demonstrated by education or training, such as 
     nurses, social workers, educators, child development 
     specialists, or other well-trained and competent staff, and 
     provides ongoing and specific training on the model being 
     delivered.
       ``(iii) The program maintains high quality supervision to 
     establish home visitor competencies.
       ``(iv) The program demonstrates strong organizational 
     capacity to implement the activities involved.
       ``(v) The program establishes appropriate linkages and 
     referral networks to other community resources and supports 
     for eligible families.
       ``(vi) The program monitors the fidelity of program 
     implementation to ensure that services are delivered pursuant 
     to the specified model.
       ``(4) Priority for serving high-risk populations.--The 
     eligible entity gives priority to providing services under 
     the program to the following:
       ``(A) Eligible families who reside in communities in need 
     of such services, as identified in the statewide needs 
     assessment required under subsection (b)(1)(A).
       ``(B) Low-income eligible families.
       ``(C) Eligible families who are pregnant women who have not 
     attained age 21.
       ``(D) Eligible families that have a history of child abuse 
     or neglect or have had interactions with child welfare 
     services.
       ``(E) Eligible families that have a history of substance 
     abuse or need substance abuse treatment.
       ``(F) Eligible families that have users of tobacco products 
     in the home.
       ``(G) Eligible families that are or have children with low 
     student achievement.
       ``(H) Eligible families with children with developmental 
     delays or disabilities.
       ``(I) Eligible families who, or that include individuals 
     who, are serving or formerly served in the Armed Forces, 
     including such families that have members of the Armed Forces 
     who have had multiple deployments outside of the United 
     States.
       ``(e) Application Requirements.--An eligible entity 
     desiring a grant under this section shall submit an 
     application to the Secretary for approval, in such manner as 
     the Secretary may require, that includes the following:
       ``(1) A description of the populations to be served by the 
     entity, including specific information regarding how the 
     entity will serve high risk populations described in 
     subsection (d)(4).
       ``(2) An assurance that the entity will give priority to 
     serving low-income eligible families and eligible families 
     who reside in at risk communities identified in the statewide 
     needs assessment required under subsection (b)(1)(A).
       ``(3) The service delivery model or models described in 
     subsection (d)(3)(A) that the entity will use under the 
     program and the basis for the selection of the model or 
     models.
       ``(4) A statement identifying how the selection of the 
     populations to be served and the service delivery model or 
     models that the entity will use under the program for such 
     populations is consistent with the results of the statewide 
     needs assessment conducted under subsection (b).
       ``(5) The quantifiable, measurable benchmarks established 
     by the State to demonstrate that the program contributes to 
     improvements in the areas specified in subsection (d)(1)(A).
       ``(6) An assurance that the entity will obtain and submit 
     documentation or other appropriate evidence from the 
     organization or entity that developed the service delivery 
     model or models used under the program to verify that the 
     program is implemented and services are delivered according 
     to the model specifications.
       ``(7) Assurances that the entity will establish procedures 
     to ensure that--
       ``(A) the participation of each eligible family in the 
     program is voluntary; and
       ``(B) services are provided to an eligible family in 
     accordance with the individual assessment for that family.
       ``(8) Assurances that the entity will--
       ``(A) submit annual reports to the Secretary regarding the 
     program and activities carried out under the program that 
     include such information and data as the Secretary shall 
     require; and
       ``(B) participate in, and cooperate with, data and 
     information collection necessary for the evaluation required 
     under subsection (g)(2) and other research and evaluation 
     activities carried out under subsection (h)(3).
       ``(9) A description of other State programs that include 
     home visitation services, including, if applicable to the 
     State, other programs carried out under this title with funds 
     made available from allotments under section 502(c), programs 
     funded under title IV, title II of the Child Abuse Prevention 
     and Treatment Act (relating to community-based grants for the 
     prevention of child abuse and neglect), and section 645A of 
     the Head Start Act (relating to Early Head Start programs).
       ``(10) Other information as required by the Secretary.
       ``(f) Maintenance of Effort.--Funds provided to an eligible 
     entity receiving a grant under this section shall supplement, 
     and not supplant, funds from other sources for early 
     childhood home visitation programs or initiatives.
       ``(g) Evaluation.--
       ``(1) Independent, expert advisory panel.--The Secretary, 
     in accordance with subsection (h)(1)(A), shall appoint an 
     independent advisory panel consisting of experts in program 
     evaluation and research, education, and early childhood 
     development--
       ``(A) to review, and make recommendations on, the design 
     and plan for the evaluation required under paragraph (2) 
     within 1 year after the date of enactment of this section;
       ``(B) to maintain and advise the Secretary regarding the 
     progress of the evaluation; and
       ``(C) to comment, if the panel so desires, on the report 
     submitted under paragraph (3).

[[Page 4263]]

       ``(2) Authority to conduct evaluation.--On the basis of the 
     recommendations of the advisory panel under paragraph (1), 
     the Secretary shall, by grant, contract, or interagency 
     agreement, conduct an evaluation of the statewide needs 
     assessments submitted under subsection (b) and the grants 
     made under subsections (c) and (h)(3)(B). The evaluation 
     shall include--
       ``(A) an analysis, on a State-by-State basis, of the 
     results of such assessments, including indicators of maternal 
     and prenatal health and infant health and mortality, and 
     State actions in response to the assessments; and
       ``(B) an assessment of--
       ``(i) the effect of early childhood home visitation 
     programs on child and parent outcomes, including with respect 
     to each of the benchmark areas specified in subsection 
     (d)(1)(A) and the participant outcomes described in 
     subsection (d)(2)(B);
       ``(ii) the effectiveness of such programs on different 
     populations, including the extent to which the ability of 
     programs to improve participant outcomes varies across 
     programs and populations; and
       ``(iii) the potential for the activities conducted under 
     such programs, if scaled broadly, to improve health care 
     practices, eliminate health disparities, and improve health 
     care system quality, efficiencies, and reduce costs.
       ``(3) Report.--Not later than March 31, 2015, the Secretary 
     shall submit a report to Congress on the results of the 
     evaluation conducted under paragraph (2) and shall make the 
     report publicly available.
       ``(h) Other Provisions.--
       ``(1) Intra-agency collaboration.--The Secretary shall 
     ensure that the Maternal and Child Health Bureau and the 
     Administration for Children and Families collaborate with 
     respect to carrying out this section, including with respect 
     to--
       ``(A) reviewing and analyzing the statewide needs 
     assessments required under subsection (b), the awarding and 
     oversight of grants awarded under this section, the 
     establishment of the advisory panels required under 
     subsections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation 
     and report required under subsection (g); and
       ``(B) consulting with other Federal agencies with 
     responsibility for administering or evaluating programs that 
     serve eligible families to coordinate and collaborate with 
     respect to research related to such programs and families, 
     including the Office of the Assistant Secretary for Planning 
     and Evaluation of the Department of Health and Human 
     Services, the Centers for Disease Control and Prevention, the 
     National Institute of Child Health and Human Development of 
     the National Institutes of Health, the Office of Juvenile 
     Justice and Delinquency Prevention of the Department of 
     Justice, and the Institute of Education Sciences of the 
     Department of Education.
       ``(2) Grants to eligible entities that are not states.--
       ``(A) Indian tribes, tribal organizations, or urban indian 
     organizations.--The Secretary shall specify requirements for 
     eligible entities that are Indian Tribes (or a consortium of 
     Indian Tribes), Tribal Organizations, or Urban Indian 
     Organizations to apply for and conduct an early childhood 
     home visitation program with a grant under this section. Such 
     requirements shall, to the greatest extent practicable, be 
     consistent with the requirements applicable to eligible 
     entities that are States and shall require an Indian Tribe 
     (or consortium), Tribal Organization, or Urban Indian 
     Organization to--
       ``(i) conduct a needs assessment similar to the assessment 
     required for all States under subsection (b); and
       ``(ii) establish quantifiable, measurable 3- and 5-year 
     benchmarks consistent with subsection (d)(1)(A).
       ``(B) Nonprofit organizations.--If, as of the beginning of 
     fiscal year 2012, a State has not applied or been approved 
     for a grant under this section, the Secretary may use amounts 
     appropriated under paragraph (1) of subsection (j) that are 
     available for expenditure under paragraph (3) of that 
     subsection to make a grant to an eligible entity that is a 
     nonprofit organization described in subsection (k)(1)(B) to 
     conduct an early childhood home visitation program in the 
     State. The Secretary shall specify the requirements for such 
     an organization to apply for and conduct the program which 
     shall, to the greatest extent practicable, be consistent with 
     the requirements applicable to eligible entities that are 
     States and shall require the organization to--
       ``(i) carry out the program based on the needs assessment 
     conducted by the State under subsection (b); and
       ``(ii) establish quantifiable, measurable 3- and 5-year 
     benchmarks consistent with subsection (d)(1)(A).
       ``(3) Research and other evaluation activities.--
       ``(A) In general.--The Secretary shall carry out a 
     continuous program of research and evaluation activities in 
     order to increase knowledge about the implementation and 
     effectiveness of home visiting programs, using random 
     assignment designs to the maximum extent feasible. The 
     Secretary may carry out such activities directly, or through 
     grants, cooperative agreements, or contracts.
       ``(B) Requirements.--The Secretary shall ensure that--
       ``(i) evaluation of a specific program or project is 
     conducted by persons or individuals not directly involved in 
     the operation of such program or project; and
       ``(ii) the conduct of research and evaluation activities 
     includes consultation with independent researchers, State 
     officials, and developers and providers of home visiting 
     programs on topics including research design and 
     administrative data matching.
       ``(4) Report and recommendation.--Not later than December 
     31, 2015, the Secretary shall submit a report to Congress 
     regarding the programs conducted with grants under this 
     section. The report required under this paragraph shall 
     include--
       ``(A) information regarding the extent to which eligible 
     entities receiving grants under this section demonstrated 
     improvements in each of the areas specified in subsection 
     (d)(1)(A);
       ``(B) information regarding any technical assistance 
     provided under subsection (d)(1)(B)(iii)(I), including the 
     type of any such assistance provided; and
       ``(C) recommendations for such legislative or 
     administrative action as the Secretary determines 
     appropriate.
       ``(i) Application of Other Provisions of Title.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under this section to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(B) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(C) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(D) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(E) Section 507 (relating to penalties for false 
     statements).
       ``(F) Section 508 (relating to nondiscrimination).
       ``(G) Section 509(a) (relating to the administration of the 
     grant program).
       ``(j) Appropriations.--
       ``(1) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary to carry out this section--
       ``(A) $100,000,000 for fiscal year 2010;
       ``(B) $250,000,000 for fiscal year 2011;
       ``(C) $350,000,000 for fiscal year 2012;
       ``(D) $400,000,000 for fiscal year 2013; and
       ``(E) $400,000,000 for fiscal year 2014.
       ``(2) Reservations.--Of the amount appropriated under this 
     subsection for a fiscal year, the Secretary shall reserve--
       ``(A) 3 percent of such amount for purposes of making 
     grants to eligible entities that are Indian Tribes (or a 
     consortium of Indian Tribes), Tribal Organizations, or Urban 
     Indian Organizations; and
       ``(B) 3 percent of such amount for purposes of carrying out 
     subsections (d)(1)(B)(iii), (g), and (h)(3).
       ``(3) Availability.--Funds made available to an eligible 
     entity under this section for a fiscal year shall remain 
     available for expenditure by the eligible entity through the 
     end of the second succeeding fiscal year after award. Any 
     funds that are not expended by the eligible entity during the 
     period in which the funds are available under the preceding 
     sentence may be used for grants to nonprofit organizations 
     under subsection (h)(2)(B).
       ``(k) Definitions.--In this section:
       ``(1) Eligible entity.--
       ``(A) In general.--The term `eligible entity' means a 
     State, an Indian Tribe, Tribal Organization, or Urban Indian 
     Organization, Puerto Rico, Guam, the Virgin Islands, the 
     Northern Mariana Islands, and American Samoa.
       ``(B) Nonprofit organizations.--Only for purposes of 
     awarding grants under subsection (h)(2)(B), such term shall 
     include a nonprofit organization with an established record 
     of providing early childhood home visitation programs or 
     initiatives in a State or several States.
       ``(2) Eligible family.--The term `eligible family' means--
       ``(A) a woman who is pregnant, and the father of the child 
     if the father is available; or
       ``(B) a parent or primary caregiver of a child, including 
     grandparents or other relatives of the child, and foster 
     parents, who are serving as the child's primary caregiver 
     from birth to kindergarten entry, and including a 
     noncustodial parent who has an ongoing relationship with, and 
     at times provides physical care for, the child.
       ``(3) Indian tribe; tribal organization.--The terms `Indian 
     Tribe' and `Tribal Organization', and `Urban Indian 
     Organization' have the meanings given such terms in section 4 
     of the Indian Health Care Improvement Act.''.

     SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM 
                   DEPRESSION.

       (a) Research on Postpartum Conditions.--
       (1) Expansion and intensification of activities.--The 
     Secretary of Health and Human Services (in this subsection 
     and subsection (c) referred to as the ``Secretary'') is 
     encouraged to continue activities on postpartum depression or 
     postpartum psychosis (in this subsection and subsection (c) 
     referred to as ``postpartum conditions''), including research 
     to expand the understanding of the causes of, and treatments 
     for, postpartum conditions. Activities under this paragraph 
     shall include conducting and supporting the following:
       (A) Basic research concerning the etiology and causes of 
     the conditions.
       (B) Epidemiological studies to address the frequency and 
     natural history of the conditions

[[Page 4264]]

     and the differences among racial and ethnic groups with 
     respect to the conditions.
       (C) The development of improved screening and diagnostic 
     techniques.
       (D) Clinical research for the development and evaluation of 
     new treatments.
       (E) Information and education programs for health care 
     professionals and the public, which may include a coordinated 
     national campaign to increase the awareness and knowledge of 
     postpartum conditions. Activities under such a national 
     campaign may--
       (i) include public service announcements through 
     television, radio, and other means; and
       (ii) focus on--

       (I) raising awareness about screening;
       (II) educating new mothers and their families about 
     postpartum conditions to promote earlier diagnosis and 
     treatment; and
       (III) ensuring that such education includes complete 
     information concerning postpartum conditions, including its 
     symptoms, methods of coping with the illness, and treatment 
     resources.

       (2) Sense of congress regarding longitudinal study of 
     relative mental health consequences for women of resolving a 
     pregnancy.--
       (A) Sense of congress.--It is the sense of Congress that 
     the Director of the National Institute of Mental Health may 
     conduct a nationally representative longitudinal study 
     (during the period of fiscal years 2010 through 2019) of the 
     relative mental health consequences for women of resolving a 
     pregnancy (intended and unintended) in various ways, 
     including carrying the pregnancy to term and parenting the 
     child, carrying the pregnancy to term and placing the child 
     for adoption, miscarriage, and having an abortion. This study 
     may assess the incidence, timing, magnitude, and duration of 
     the immediate and long-term mental health consequences 
     (positive or negative) of these pregnancy outcomes.
       (B) Report.--Subject to the completion of the study under 
     subsection (a), beginning not later than 5 years after the 
     date of the enactment of this Act, and periodically 
     thereafter for the duration of the study, such Director may 
     prepare and submit to the Congress reports on the findings of 
     the study.
       (b) Grants To Provide Services to Individuals With a 
     Postpartum Condition and Their Families.--Title V of the 
     Social Security Act (42 U.S.C. 701 et seq.), as amended by 
     section 2951, is amended by adding at the end the following 
     new section:

     ``SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM 
                   CONDITION AND THEIR FAMILIES.

       ``(a) In General.--In addition to any other payments made 
     under this title to a State, the Secretary may make grants to 
     eligible entities for projects for the establishment, 
     operation, and coordination of effective and cost-efficient 
     systems for the delivery of essential services to individuals 
     with or at risk for postpartum conditions and their families.
       ``(b) Certain Activities.--To the extent practicable and 
     appropriate, the Secretary shall ensure that projects funded 
     under subsection (a) provide education and services with 
     respect to the diagnosis and management of postpartum 
     conditions for individuals with or at risk for postpartum 
     conditions and their families. The Secretary may allow such 
     projects to include the following:
       ``(1) Delivering or enhancing outpatient and home-based 
     health and support services, including case management and 
     comprehensive treatment services.
       ``(2) Delivering or enhancing inpatient care management 
     services that ensure the well-being of the mother and family 
     and the future development of the infant.
       ``(3) Improving the quality, availability, and organization 
     of health care and support services (including transportation 
     services, attendant care, homemaker services, day or respite 
     care, and providing counseling on financial assistance and 
     insurance).
       ``(4) Providing education about postpartum conditions to 
     promote earlier diagnosis and treatment. Such education may 
     include--
       ``(A) providing complete information on postpartum 
     conditions, symptoms, methods of coping with the illness, and 
     treatment resources; and
       ``(B) in the case of a grantee that is a State, hospital, 
     or birthing facility--
       ``(i) providing education to new mothers and fathers, and 
     other family members as appropriate, concerning postpartum 
     conditions before new mothers leave the health facility; and
       ``(ii) ensuring that training programs regarding such 
     education are carried out at the health facility.
       ``(c) Integration With Other Programs.--To the extent 
     practicable and appropriate, the Secretary may integrate the 
     grant program under this section with other grant programs 
     carried out by the Secretary, including the program under 
     section 330 of the Public Health Service Act.
       ``(d) Requirements.--The Secretary shall establish 
     requirements for grants made under this section that include 
     a limit on the amount of grants funds that may be used for 
     administration, accounting, reporting, or program oversight 
     functions and a requirement for each eligible entity that 
     receives a grant to submit, for each grant period, a report 
     to the Secretary that describes how grant funds were used 
     during such period.
       ``(e) Technical Assistance.--The Secretary may provide 
     technical assistance to entities seeking a grant under this 
     section in order to assist such entities in complying with 
     the requirements of this section.
       ``(f) Application of Other Provisions of Title.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under this section to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(B) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(C) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(D) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(E) Section 507 (relating to penalties for false 
     statements).
       ``(F) Section 508 (relating to nondiscrimination).
       ``(G) Section 509(a) (relating to the administration of the 
     grant program).
       ``(g) Definitions.--In this section:
       ``(1) The term `eligible entity'--
       ``(A) means a public or nonprofit private entity; and
       ``(B) includes a State or local government, public-private 
     partnership, recipient of a grant under section 330H of the 
     Public Health Service Act (relating to the Healthy Start 
     Initiative), public or nonprofit private hospital, community-
     based organization, hospice, ambulatory care facility, 
     community health center, migrant health center, public 
     housing primary care center, or homeless health center.
       ``(2) The term `postpartum condition' means postpartum 
     depression or postpartum psychosis.''.
       (c) General Provisions.--
       (1) Authorization of appropriations.--To carry out this 
     section and the amendment made by subsection (b), there are 
     authorized to be appropriated, in addition to such other sums 
     as may be available for such purpose--
       (A) $3,000,000 for fiscal year 2010; and
       (B) such sums as may be necessary for fiscal years 2011 and 
     2012.
       (2) Report by the secretary.--
       (A) Study.--The Secretary shall conduct a study on the 
     benefits of screening for postpartum conditions.
       (B) Report.--Not later than 2 years after the date of the 
     enactment of this Act, the Secretary shall complete the study 
     required by subparagraph (A) and submit a report to the 
     Congress on the results of such study.

     SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.), 
     as amended by sections 2951 and 2952(c), is amended by adding 
     at the end the following:

     ``SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.

       ``(a) Allotments to States.--
       ``(1) Amount.--
       ``(A) In general.--For the purpose described in subsection 
     (b), subject to the succeeding provisions of this section, 
     for each of fiscal years 2010 through 2014, the Secretary 
     shall allot to each State an amount equal to the product of--
       ``(i) the amount appropriated under subsection (f) for the 
     fiscal year and available for allotments to States after the 
     application of subsection (c); and
       ``(ii) the State youth population percentage determined 
     under paragraph (2).
       ``(B) Minimum allotment.--
       ``(i) In general.--Each State allotment under this 
     paragraph for a fiscal year shall be at least $250,000.
       ``(ii) Pro rata adjustments.--The Secretary shall adjust on 
     a pro rata basis the amount of the State allotments 
     determined under this paragraph for a fiscal year to the 
     extent necessary to comply with clause (i).
       ``(C) Application required to access allotments.--
       ``(i) In general.--A State shall not be paid from its 
     allotment for a fiscal year unless the State submits an 
     application to the Secretary for the fiscal year and the 
     Secretary approves the application (or requires changes to 
     the application that the State satisfies) and meets such 
     additional requirements as the Secretary may specify.
       ``(ii) Requirements.--The State application shall contain 
     an assurance that the State has complied with the 
     requirements of this section in preparing and submitting the 
     application and shall include the following as well as such 
     additional information as the Secretary may require:

       ``(I) Based on data from the Centers for Disease Control 
     and Prevention National Center for Health Statistics, the 
     most recent pregnancy rates for the State for youth ages 10 
     to 14 and youth ages 15 to 19 for which data are available, 
     the most recent birth rates for such youth populations in the 
     State for which data are available, and trends in those rates 
     for the most recently preceding 5-year period for which such 
     data are available.
       ``(II) State-established goals for reducing the pregnancy 
     rates and birth rates for such youth populations.
       ``(III) A description of the State's plan for using the 
     State allotments provided under this section to achieve such 
     goals, especially among youth populations that are the most 
     high-risk or

[[Page 4265]]

     vulnerable for pregnancies or otherwise have special 
     circumstances, including youth in foster care, homeless 
     youth, youth with HIV/AIDS, pregnant youth who are under 21 
     years of age, mothers who are under 21 years of age, and 
     youth residing in areas with high birth rates for youth.

       ``(2) State youth population percentage.--
       ``(A) In general.--For purposes of paragraph (1)(A)(ii), 
     the State youth population percentage is, with respect to a 
     State, the proportion (expressed as a percentage) of--
       ``(i) the number of individuals who have attained age 10 
     but not attained age 20 in the State; to
       ``(ii) the number of such individuals in all States.
       ``(B) Determination of number of youth.--The number of 
     individuals described in clauses (i) and (ii) of subparagraph 
     (A) in a State shall be determined on the basis of the most 
     recent Bureau of the Census data.
       ``(3) Availability of state allotments.--Subject to 
     paragraph (4)(A), amounts allotted to a State pursuant to 
     this subsection for a fiscal year shall remain available for 
     expenditure by the State through the end of the second 
     succeeding fiscal year.
       ``(4) Authority to award grants from state allotments to 
     local organizations and entities in nonparticipating 
     states.--
       ``(A) Grants from unexpended allotments.--If a State does 
     not submit an application under this section for fiscal year 
     2010 or 2011, the State shall no longer be eligible to submit 
     an application to receive funds from the amounts allotted for 
     the State for each of fiscal years 2010 through 2014 and such 
     amounts shall be used by the Secretary to award grants under 
     this paragraph for each of fiscal years 2012 through 2014. 
     The Secretary also shall use any amounts from the allotments 
     of States that submit applications under this section for a 
     fiscal year that remain unexpended as of the end of the 
     period in which the allotments are available for expenditure 
     under paragraph (3) for awarding grants under this paragraph.
       ``(B) 3-year grants.--
       ``(i) In general.--The Secretary shall solicit applications 
     to award 3-year grants in each of fiscal years 2012, 2013, 
     and 2014 to local organizations and entities to conduct, 
     consistent with subsection (b), programs and activities in 
     States that do not submit an application for an allotment 
     under this section for fiscal year 2010 or 2011.
       ``(ii) Faith-based organizations or consortia.--The 
     Secretary may solicit and award grants under this paragraph 
     to faith-based organizations or consortia.
       ``(C) Evaluation.--An organization or entity awarded a 
     grant under this paragraph shall agree to participate in a 
     rigorous Federal evaluation.
       ``(5) Maintenance of effort.--No payment shall be made to a 
     State from the allotment determined for the State under this 
     subsection or to a local organization or entity awarded a 
     grant under paragraph (4), if the expenditure of non-federal 
     funds by the State, organization, or entity for activities, 
     programs, or initiatives for which amounts from allotments 
     and grants under this subsection may be expended is less than 
     the amount expended by the State, organization, or entity for 
     such programs or initiatives for fiscal year 2009.
       ``(6) Data collection and reporting.--A State or local 
     organization or entity receiving funds under this section 
     shall cooperate with such requirements relating to the 
     collection of data and information and reporting on outcomes 
     regarding the programs and activities carried out with such 
     funds, as the Secretary shall specify.
       ``(b) Purpose.--
       ``(1) In general.--The purpose of an allotment under 
     subsection (a)(1) to a State is to enable the State (or, in 
     the case of grants made under subsection (a)(4)(B), to enable 
     a local organization or entity) to carry out personal 
     responsibility education programs consistent with this 
     subsection.
       ``(2) Personal responsibility education programs.--
       ``(A) In general.--In this section, the term `personal 
     responsibility education program' means a program that is 
     designed to educate adolescents on--
       ``(i) both abstinence and contraception for the prevention 
     of pregnancy and sexually transmitted infections, including 
     HIV/AIDS, consistent with the requirements of subparagraph 
     (B); and
       ``(ii) at least 3 of the adulthood preparation subjects 
     described in subparagraph (C).
       ``(B) Requirements.--The requirements of this subparagraph 
     are the following:
       ``(i) The program replicates evidence-based effective 
     programs or substantially incorporates elements of effective 
     programs that have been proven on the basis of rigorous 
     scientific research to change behavior, which means delaying 
     sexual activity, increasing condom or contraceptive use for 
     sexually active youth, or reducing pregnancy among youth.
       ``(ii) The program is medically-accurate and complete.
       ``(iii) The program includes activities to educate youth 
     who are sexually active regarding responsible sexual behavior 
     with respect to both abstinence and the use of contraception.
       ``(iv) The program places substantial emphasis on both 
     abstinence and contraception for the prevention of pregnancy 
     among youth and sexually transmitted infections.
       ``(v) The program provides age-appropriate information and 
     activities.
       ``(vi) The information and activities carried out under the 
     program are provided in the cultural context that is most 
     appropriate for individuals in the particular population 
     group to which they are directed.
       ``(C) Adulthood preparation subjects.--The adulthood 
     preparation subjects described in this subparagraph are the 
     following:
       ``(i) Healthy relationships, such as positive self-esteem 
     and relationship dynamics, friendships, dating, romantic 
     involvement, marriage, and family interactions.
       ``(ii) Adolescent development, such as the development of 
     healthy attitudes and values about adolescent growth and 
     development, body image, racial and ethnic diversity, and 
     other related subjects.
       ``(iii) Financial literacy.
       ``(iv) Parent-child communication.
       ``(v) Educational and career success, such as developing 
     skills for employment preparation, job seeking, independent 
     living, financial self-sufficiency, and workplace 
     productivity.
       ``(vi) Healthy life skills, such as goal-setting, decision 
     making, negotiation, communication and interpersonal skills, 
     and stress management.
       ``(c) Reservations of Funds.--
       ``(1) Grants to implement innovative strategies.--From the 
     amount appropriated under subsection (f) for the fiscal year, 
     the Secretary shall reserve $10,000,000 of such amount for 
     purposes of awarding grants to entities to implement 
     innovative youth pregnancy prevention strategies and target 
     services to high-risk, vulnerable, and culturally under-
     represented youth populations, including youth in foster 
     care, homeless youth, youth with HIV/AIDS, pregnant women who 
     are under 21 years of age and their partners, mothers who are 
     under 21 years of age and their partners, and youth residing 
     in areas with high birth rates for youth. An entity awarded a 
     grant under this paragraph shall agree to participate in a 
     rigorous Federal evaluation of the activities carried out 
     with grant funds.
       ``(2) Other reservations.--From the amount appropriated 
     under subsection (f) for the fiscal year that remains after 
     the application of paragraph (1), the Secretary shall reserve 
     the following amounts:
       ``(A) Grants for indian tribes or tribal organizations.--
     The Secretary shall reserve 5 percent of such remainder for 
     purposes of awarding grants to Indian tribes and tribal 
     organizations in such manner, and subject to such 
     requirements, as the Secretary, in consultation with Indian 
     tribes and tribal organizations, determines appropriate.
       ``(B) Secretarial responsibilities.--
       ``(i) Reservation of funds.--The Secretary shall reserve 10 
     percent of such remainder for expenditures by the Secretary 
     for the activities described in clauses (ii) and (iii).
       ``(ii) Program support.--The Secretary shall provide, 
     directly or through a competitive grant process, research, 
     training and technical assistance, including dissemination of 
     research and information regarding effective and promising 
     practices, providing consultation and resources on a broad 
     array of teen pregnancy prevention strategies, including 
     abstinence and contraception, and developing resources and 
     materials to support the activities of recipients of grants 
     and other State, tribal, and community organizations working 
     to reduce teen pregnancy. In carrying out such functions, the 
     Secretary shall collaborate with a variety of entities that 
     have expertise in the prevention of teen pregnancy, HIV and 
     sexually transmitted infections, healthy relationships, 
     financial literacy, and other topics addressed through the 
     personal responsibility education programs.
       ``(iii) Evaluation.--The Secretary shall evaluate the 
     programs and activities carried out with funds made available 
     through allotments or grants under this section.
       ``(d) Administration.--
       ``(1) In general.--The Secretary shall administer this 
     section through the Assistant Secretary for the 
     Administration for Children and Families within the 
     Department of Health and Human Services.
       ``(2) Application of other provisions of title.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the other provisions of this title shall not apply to 
     allotments or grants made under this section.
       ``(B) Exceptions.--The following provisions of this title 
     shall apply to allotments and grants made under this section 
     to the same extent and in the same manner as such provisions 
     apply to allotments made under section 502(c):
       ``(i) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(ii) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(iii) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(iv) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(v) Section 507 (relating to penalties for false 
     statements).
       ``(vi) Section 508 (relating to nondiscrimination).
       ``(e) Definitions.--In this section:
       ``(1) Age-appropriate.--The term `age-appropriate', with 
     respect to the information in pregnancy prevention, means 
     topics, messages, and teaching methods suitable to particular 
     ages or age groups of children and adolescents, based

[[Page 4266]]

     on developing cognitive, emotional, and behavioral capacity 
     typical for the age or age group.
       ``(2) Medically accurate and complete.--The term `medically 
     accurate and complete' means verified or supported by the 
     weight of research conducted in compliance with accepted 
     scientific methods and--
       ``(A) published in peer-reviewed journals, where 
     applicable; or
       ``(B) comprising information that leading professional 
     organizations and agencies with relevant expertise in the 
     field recognize as accurate, objective, and complete.
       ``(3) Indian tribes; tribal organizations.--The terms 
     `Indian tribe' and `Tribal organization' have the meanings 
     given such terms in section 4 of the Indian Health Care 
     Improvement Act (25 U.S.C. 1603)).
       ``(4) Youth.--The term `youth' means an individual who has 
     attained age 10 but has not attained age 20.
       ``(f) Appropriation.--For the purpose of carrying out this 
     section, there is appropriated, out of any money in the 
     Treasury not otherwise appropriated, $75,000,000 for each of 
     fiscal years 2010 through 2014. Amounts appropriated under 
     this subsection shall remain available until expended.''.

     SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION.

       Section 510 of the Social Security Act (42 U.S.C. 710) is 
     amended--
       (1) in subsection (a), by striking ``fiscal year 1998 and 
     each subsequent fiscal year'' and inserting ``each of fiscal 
     years 2010 through 2014''; and
       (2) in subsection (d)--
       (A) in the first sentence, by striking ``1998 through 
     2003'' and inserting ``2010 through 2014''; and
       (B) in the second sentence, by inserting ``(except that 
     such appropriation shall be made on the date of enactment of 
     the Patient Protection and Affordable Care Act in the case of 
     fiscal year 2010)'' before the period.

     SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF 
                   HAVING A HEALTH CARE POWER OF ATTORNEY IN 
                   TRANSITION PLANNING FOR CHILDREN AGING OUT OF 
                   FOSTER CARE AND INDEPENDENT LIVING PROGRAMS.

       (a) Transition Planning.--Section 475(5)(H) of the Social 
     Security Act (42 U.S.C. 675(5)(H)) is amended by inserting 
     ``includes information about the importance of designating 
     another individual to make health care treatment decisions on 
     behalf of the child if the child becomes unable to 
     participate in such decisions and the child does not have, or 
     does not want, a relative who would otherwise be authorized 
     under State law to make such decisions, and provides the 
     child with the option to execute a health care power of 
     attorney, health care proxy, or other similar document 
     recognized under State law,'' after ``employment services,''.
       (b) Independent Living Education.--Section 477(b)(3) of 
     such Act (42 U.S.C. 677(b)(3)) is amended by adding at the 
     end the following:
       ``(K) A certification by the chief executive officer of the 
     State that the State will ensure that an adolescent 
     participating in the program under this section are provided 
     with education about the importance of designating another 
     individual to make health care treatment decisions on behalf 
     of the adolescent if the adolescent becomes unable to 
     participate in such decisions and the adolescent does not 
     have, or does not want, a relative who would otherwise be 
     authorized under State law to make such decisions, whether a 
     health care power of attorney, health care proxy, or other 
     similar document is recognized under State law, and how to 
     execute such a document if the adolescent wants to do so.''.
       (c) Health Oversight and Coordination Plan.--Section 
     422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is 
     amended--
       (1) in clause (v), by striking ``and'' at the end; and
       (2) by adding at the end the following:
       ``(vii) steps to ensure that the components of the 
     transition plan development process required under section 
     475(5)(H) that relate to the health care needs of children 
     aging out of foster care, including the requirements to 
     include options for health insurance, information about a 
     health care power of attorney, health care proxy, or other 
     similar document recognized under State law, and to provide 
     the child with the option to execute such a document, are 
     met; and''.
       (d) Effective Date.--The amendments made by this section 
     take effect on October 1, 2010.

     TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE

        Subtitle A--Transforming the Health Care Delivery System

 PART I--LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM

     SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM.

       (a) Program.--
       (1) In general.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww), as amended by section 4102(a) of the 
     HITECH Act (Public Law 111-5), is amended by adding at the 
     end the following new subsection:
       ``(o) Hospital Value-Based Purchasing Program.--
       ``(1) Establishment.--
       ``(A) In general.--Subject to the succeeding provisions of 
     this subsection, the Secretary shall establish a hospital 
     value-based purchasing program (in this subsection referred 
     to as the `Program') under which value-based incentive 
     payments are made in a fiscal year to hospitals that meet the 
     performance standards under paragraph (3) for the performance 
     period for such fiscal year (as established under paragraph 
     (4)).
       ``(B) Program to begin in fiscal year 2013.--The Program 
     shall apply to payments for discharges occurring on or after 
     October 1, 2012.
       ``(C) Applicability of program to hospitals.--
       ``(i) In general.--For purposes of this subsection, subject 
     to clause (ii), the term `hospital' means a subsection (d) 
     hospital (as defined in subsection (d)(1)(B)).
       ``(ii) Exclusions.--The term `hospital' shall not include, 
     with respect to a fiscal year, a hospital--

       ``(I) that is subject to the payment reduction under 
     subsection (b)(3)(B)(viii)(I) for such fiscal year;
       ``(II) for which, during the performance period for such 
     fiscal year, the Secretary has cited deficiencies that pose 
     immediate jeopardy to the health or safety of patients;
       ``(III) for which there are not a minimum number (as 
     determined by the Secretary) of measures that apply to the 
     hospital for the performance period for such fiscal year; or
       ``(IV) for which there are not a minimum number (as 
     determined by the Secretary) of cases for the measures that 
     apply to the hospital for the performance period for such 
     fiscal year.

       ``(iii) Independent analysis.--For purposes of determining 
     the minimum numbers under subclauses (III) and (IV) of clause 
     (ii), the Secretary shall have conducted an independent 
     analysis of what numbers are appropriate.
       ``(iv) Exemption.--In the case of a hospital that is paid 
     under section 1814(b)(3), the Secretary may exempt such 
     hospital from the application of this subsection if the State 
     which is paid under such section submits an annual report to 
     the Secretary describing how a similar program in the State 
     for a participating hospital or hospitals achieves or 
     surpasses the measured results in terms of patient health 
     outcomes and cost savings established under this subsection.
       ``(2) Measures.--
       ``(A) In general.--The Secretary shall select measures for 
     purposes of the Program. Such measures shall be selected from 
     the measures specified under subsection (b)(3)(B)(viii).
       ``(B) Requirements.--
       ``(i) For fiscal year 2013.--For value-based incentive 
     payments made with respect to discharges occurring during 
     fiscal year 2013, the Secretary shall ensure the following:

       ``(I) Conditions or procedures.--Measures are selected 
     under subparagraph (A) that cover at least the following 5 
     specific conditions or procedures:

       ``(aa) Acute myocardial infarction (AMI).
       ``(bb) Heart failure.
       ``(cc) Pneumonia.
       ``(dd) Surgeries, as measured by the Surgical Care 
     Improvement Project (formerly referred to as `Surgical 
     Infection Prevention' for discharges occurring before July 
     2006).
       ``(ee) Healthcare-associated infections, as measured by the 
     prevention metrics and targets established in the HHS Action 
     Plan to Prevent Healthcare-Associated Infections (or any 
     successor plan) of the Department of Health and Human 
     Services.

       ``(II) HCAHPS.--Measures selected under subparagraph (A) 
     shall be related to the Hospital Consumer Assessment of 
     Healthcare Providers and Systems survey (HCAHPS).

       ``(ii) Inclusion of efficiency measures.--For value-based 
     incentive payments made with respect to discharges occurring 
     during fiscal year 2014 or a subsequent fiscal year, the 
     Secretary shall ensure that measures selected under 
     subparagraph (A) include efficiency measures, including 
     measures of `Medicare spending per beneficiary'. Such 
     measures shall be adjusted for factors such as age, sex, 
     race, severity of illness, and other factors that the 
     Secretary determines appropriate.
       ``(C) Limitations.--
       ``(i) Time requirement for prior reporting and notice.--The 
     Secretary may not select a measure under subparagraph (A) for 
     use under the Program with respect to a performance period 
     for a fiscal year (as established under paragraph (4)) unless 
     such measure has been specified under subsection 
     (b)(3)(B)(viii) and included on the Hospital Compare Internet 
     website for at least 1 year prior to the beginning of such 
     performance period.
       ``(ii) Measure not applicable unless hospital furnishes 
     services appropriate to the measure.--A measure selected 
     under subparagraph (A) shall not apply to a hospital if such 
     hospital does not furnish services appropriate to such 
     measure.
       ``(D) Replacing measures.--Subclause (VI) of subsection 
     (b)(3)(B)(viii) shall apply to measures selected under 
     subparagraph (A) in the same manner as such subclause applies 
     to measures selected under such subsection.
       ``(3) Performance standards.--
       ``(A) Establishment.--The Secretary shall establish 
     performance standards with respect to measures selected under 
     paragraph (2) for a performance period for a fiscal year (as 
     established under paragraph (4)).
       ``(B) Achievement and improvement.--The performance 
     standards established under subparagraph (A) shall include 
     levels of achievement and improvement.
       ``(C) Timing.--The Secretary shall establish and announce 
     the performance standards under subparagraph (A) not later 
     than 60 days prior to the beginning of the performance period 
     for the fiscal year involved.

[[Page 4267]]

       ``(D) Considerations in establishing standards.--In 
     establishing performance standards with respect to measures 
     under this paragraph, the Secretary shall take into account 
     appropriate factors, such as--
       ``(i) practical experience with the measures involved, 
     including whether a significant proportion of hospitals 
     failed to meet the performance standard during previous 
     performance periods;
       ``(ii) historical performance standards;
       ``(iii) improvement rates; and
       ``(iv) the opportunity for continued improvement.
       ``(4) Performance period.--For purposes of the Program, the 
     Secretary shall establish the performance period for a fiscal 
     year. Such performance period shall begin and end prior to 
     the beginning of such fiscal year.
       ``(5) Hospital performance score.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary shall develop a methodology for assessing the total 
     performance of each hospital based on performance standards 
     with respect to the measures selected under paragraph (2) for 
     a performance period (as established under paragraph (4)). 
     Using such methodology, the Secretary shall provide for an 
     assessment (in this subsection referred to as the `hospital 
     performance score') for each hospital for each performance 
     period.
       ``(B) Application.--
       ``(i) Appropriate distribution.--The Secretary shall ensure 
     that the application of the methodology developed under 
     subparagraph (A) results in an appropriate distribution of 
     value-based incentive payments under paragraph (6) among 
     hospitals achieving different levels of hospital performance 
     scores, with hospitals achieving the highest hospital 
     performance scores receiving the largest value-based 
     incentive payments.
       ``(ii) Higher of achievement or improvement.--The 
     methodology developed under subparagraph (A) shall provide 
     that the hospital performance score is determined using the 
     higher of its achievement or improvement score for each 
     measure.
       ``(iii) Weights.--The methodology developed under 
     subparagraph (A) shall provide for the assignment of weights 
     for categories of measures as the Secretary determines 
     appropriate.
       ``(iv) No minimum performance standard.--The Secretary 
     shall not set a minimum performance standard in determining 
     the hospital performance score for any hospital.
       ``(v) Reflection of measures applicable to the hospital.--
     The hospital performance score for a hospital shall reflect 
     the measures that apply to the hospital.
       ``(6) Calculation of value-based incentive payments.--
       ``(A) In general.--In the case of a hospital that the 
     Secretary determines meets (or exceeds) the performance 
     standards under paragraph (3) for the performance period for 
     a fiscal year (as established under paragraph (4)), the 
     Secretary shall increase the base operating DRG payment 
     amount (as defined in paragraph (7)(D)), as determined after 
     application of paragraph (7)(B)(i), for a hospital for each 
     discharge occurring in such fiscal year by the value-based 
     incentive payment amount.
       ``(B) Value-based incentive payment amount.--The value-
     based incentive payment amount for each discharge of a 
     hospital in a fiscal year shall be equal to the product of--
       ``(i) the base operating DRG payment amount (as defined in 
     paragraph (7)(D)) for the discharge for the hospital for such 
     fiscal year; and
       ``(ii) the value-based incentive payment percentage 
     specified under subparagraph (C) for the hospital for such 
     fiscal year.
       ``(C) Value-based incentive payment percentage.--
       ``(i) In general.--The Secretary shall specify a value-
     based incentive payment percentage for a hospital for a 
     fiscal year.
       ``(ii) Requirements.--In specifying the value-based 
     incentive payment percentage for each hospital for a fiscal 
     year under clause (i), the Secretary shall ensure that--

       ``(I) such percentage is based on the hospital performance 
     score of the hospital under paragraph (5); and
       ``(II) the total amount of value-based incentive payments 
     under this paragraph to all hospitals in such fiscal year is 
     equal to the total amount available for value-based incentive 
     payments for such fiscal year under paragraph (7)(A), as 
     estimated by the Secretary.

       ``(7) Funding for value-based incentive payments.--
       ``(A) Amount.--The total amount available for value-based 
     incentive payments under paragraph (6) for all hospitals for 
     a fiscal year shall be equal to the total amount of reduced 
     payments for all hospitals under subparagraph (B) for such 
     fiscal year, as estimated by the Secretary.
       ``(B) Adjustment to payments.--
       ``(i) In general.--The Secretary shall reduce the base 
     operating DRG payment amount (as defined in subparagraph (D)) 
     for a hospital for each discharge in a fiscal year (beginning 
     with fiscal year 2013) by an amount equal to the applicable 
     percent (as defined in subparagraph (C)) of the base 
     operating DRG payment amount for the discharge for the 
     hospital for such fiscal year. The Secretary shall make such 
     reductions for all hospitals in the fiscal year involved, 
     regardless of whether or not the hospital has been determined 
     by the Secretary to have earned a value-based incentive 
     payment under paragraph (6) for such fiscal year.
       ``(ii) No effect on other payments.--Payments described in 
     items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital 
     shall be determined as if this subsection had not been 
     enacted.
       ``(C) Applicable percent defined.--For purposes of 
     subparagraph (B), the term `applicable percent' means--
       ``(i) with respect to fiscal year 2013, 1.0 percent;
       ``(ii) with respect to fiscal year 2014, 1.25 percent;
       ``(iii) with respect to fiscal year 2015, 1.5 percent;
       ``(iv) with respect to fiscal year 2016, 1.75 percent; and
       ``(v) with respect to fiscal year 2017 and succeeding 
     fiscal years, 2 percent.
       ``(D) Base operating drg payment amount defined.--
       ``(i) In general.--Except as provided in clause (ii), in 
     this subsection, the term `base operating DRG payment amount' 
     means, with respect to a hospital for a fiscal year--

       ``(I) the payment amount that would otherwise be made under 
     subsection (d) (determined without regard to subsection (q)) 
     for a discharge if this subsection did not apply; reduced by
       ``(II) any portion of such payment amount that is 
     attributable to--

       ``(aa) payments under paragraphs (5)(A), (5)(B), (5)(F), 
     and (12) of subsection (d); and
       ``(bb) such other payments under subsection (d) determined 
     appropriate by the Secretary.
       ``(ii) Special rules for certain hospitals.--

       ``(I) Sole community hospitals and medicare-dependent, 
     small rural hospitals.--In the case of a medicare-dependent, 
     small rural hospital (with respect to discharges occurring 
     during fiscal year 2012 and 2013) or a sole community 
     hospital, in applying subparagraph (A)(i), the payment amount 
     that would otherwise be made under subsection (d) shall be 
     determined without regard to subparagraphs (I) and (L) of 
     subsection (b)(3) and subparagraphs (D) and (G) of subsection 
     (d)(5).
       ``(II) Hospitals paid under section 1814.--In the case of a 
     hospital that is paid under section 1814(b)(3), the term 
     `base operating DRG payment amount' means the payment amount 
     under such section.

       ``(8) Announcement of net result of adjustments.--Under the 
     Program, the Secretary shall, not later than 60 days prior to 
     the fiscal year involved, inform each hospital of the 
     adjustments to payments to the hospital for discharges 
     occurring in such fiscal year under paragraphs (6) and 
     (7)(B)(i).
       ``(9) No effect in subsequent fiscal years.--The value-
     based incentive payment under paragraph (6) and the payment 
     reduction under paragraph (7)(B)(i) shall each apply only 
     with respect to the fiscal year involved, and the Secretary 
     shall not take into account such value-based incentive 
     payment or payment reduction in making payments to a hospital 
     under this section in a subsequent fiscal year.
       ``(10) Public reporting.--
       ``(A) Hospital specific information.--
       ``(i) In general.--The Secretary shall make information 
     available to the public regarding the performance of 
     individual hospitals under the Program, including--

       ``(I) the performance of the hospital with respect to each 
     measure that applies to the hospital;
       ``(II) the performance of the hospital with respect to each 
     condition or procedure; and
       ``(III) the hospital performance score assessing the total 
     performance of the hospital.

       ``(ii) Opportunity to review and submit corrections.--The 
     Secretary shall ensure that a hospital has the opportunity to 
     review, and submit corrections for, the information to be 
     made public with respect to the hospital under clause (i) 
     prior to such information being made public.
       ``(iii) Website.--Such information shall be posted on the 
     Hospital Compare Internet website in an easily understandable 
     format.
       ``(B) Aggregate information.--The Secretary shall 
     periodically post on the Hospital Compare Internet website 
     aggregate information on the Program, including--
       ``(i) the number of hospitals receiving value-based 
     incentive payments under paragraph (6) and the range and 
     total amount of such value-based incentive payments; and
       ``(ii) the number of hospitals receiving less than the 
     maximum value-based incentive payment available to the 
     hospital for the fiscal year involved and the range and 
     amount of such payments.
       ``(11) Implementation.--
       ``(A) Appeals.--The Secretary shall establish a process by 
     which hospitals may appeal the calculation of a hospital's 
     performance assessment with respect to the performance 
     standards established under paragraph (3)(A) and the hospital 
     performance score under paragraph (5). The Secretary shall 
     ensure that such process provides for resolution of such 
     appeals in a timely manner.
       ``(B) Limitation on review.--Except as provided in 
     subparagraph (A), there shall be no administrative or 
     judicial review under section 1869, section 1878, or 
     otherwise of the following:
       ``(i) The methodology used to determine the amount of the 
     value-based incentive payment under paragraph (6) and the 
     determination of such amount.
       ``(ii) The determination of the amount of funding available 
     for such value-based incentive payments under paragraph 
     (7)(A) and the payment reduction under paragraph (7)(B)(i).
       ``(iii) The establishment of the performance standards 
     under paragraph (3) and the performance period under 
     paragraph (4).

[[Page 4268]]

       ``(iv) The measures specified under subsection 
     (b)(3)(B)(viii) and the measures selected under paragraph 
     (2).
       ``(v) The methodology developed under paragraph (5) that is 
     used to calculate hospital performance scores and the 
     calculation of such scores.
       ``(vi) The validation methodology specified in subsection 
     (b)(3)(B)(viii)(XI).
       ``(C) Consultation with small hospitals.--The Secretary 
     shall consult with small rural and urban hospitals on the 
     application of the Program to such hospitals.
       ``(12) Promulgation of regulations.--The Secretary shall 
     promulgate regulations to carry out the Program, including 
     the selection of measures under paragraph (2), the 
     methodology developed under paragraph (5) that is used to 
     calculate hospital performance scores, and the methodology 
     used to determine the amount of value-based incentive 
     payments under paragraph (6).''.
       (2) Amendments for reporting of hospital quality 
     information.--Section 1886(b)(3)(B)(viii) of the Social 
     Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended--
       (A) in subclause (II), by adding at the end the following 
     sentence: ``The Secretary may require hospitals to submit 
     data on measures that are not used for the determination of 
     value-based incentive payments under subsection (o).'';
       (B) in subclause (V), by striking ``beginning with fiscal 
     year 2008'' and inserting ``for fiscal years 2008 through 
     2012'';
       (C) in subclause (VII), in the first sentence, by striking 
     ``data submitted'' and inserting ``information regarding 
     measures submitted''; and
       (D) by adding at the end the following new subclauses:
       ``(VIII) Effective for payments beginning with fiscal year 
     2013, with respect to quality measures for outcomes of care, 
     the Secretary shall provide for such risk adjustment as the 
     Secretary determines to be appropriate to maintain incentives 
     for hospitals to treat patients with severe illnesses or 
     conditions.
       ``(IX)(aa) Subject to item (bb), effective for payments 
     beginning with fiscal year 2013, each measure specified by 
     the Secretary under this clause shall be endorsed by the 
     entity with a contract under section 1890(a).
       ``(bb) In the case of a specified area or medical topic 
     determined appropriate by the Secretary for which a feasible 
     and practical measure has not been endorsed by the entity 
     with a contract under section 1890(a), the Secretary may 
     specify a measure that is not so endorsed as long as due 
     consideration is given to measures that have been endorsed or 
     adopted by a consensus organization identified by the 
     Secretary.
       ``(X) To the extent practicable, the Secretary shall, with 
     input from consensus organizations and other stakeholders, 
     take steps to ensure that the measures specified by the 
     Secretary under this clause are coordinated and aligned with 
     quality measures applicable to--
       ``(aa) physicians under section 1848(k); and
       ``(bb) other providers of services and suppliers under this 
     title.
       ``(XI) The Secretary shall establish a process to validate 
     measures specified under this clause as appropriate. Such 
     process shall include the auditing of a number of randomly 
     selected hospitals sufficient to ensure validity of the 
     reporting program under this clause as a whole and shall 
     provide a hospital with an opportunity to appeal the 
     validation of measures reported by such hospital.''.
       (3) Website improvements.--Section 1886(b)(3)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended 
     by section 4102(b) of the HITECH Act (Public Law 111-5), is 
     amended by adding at the end the following new clause:
       ``(x)(I) The Secretary shall develop standard Internet 
     website reports tailored to meet the needs of various 
     stakeholders such as hospitals, patients, researchers, and 
     policymakers. The Secretary shall seek input from such 
     stakeholders in determining the type of information that is 
     useful and the formats that best facilitate the use of the 
     information.
       ``(II) The Secretary shall modify the Hospital Compare 
     Internet website to make the use and navigation of that 
     website readily available to individuals accessing it.''.
       (4) GAO study and report.--
       (A) Study.--The Comptroller General of the United States 
     shall conduct a study on the performance of the hospital 
     value-based purchasing program established under section 
     1886(o) of the Social Security Act, as added by paragraph 
     (1). Such study shall include an analysis of the impact of 
     such program on--
       (i) the quality of care furnished to Medicare 
     beneficiaries, including diverse Medicare beneficiary 
     populations (such as diverse in terms of race, ethnicity, and 
     socioeconomic status);
       (ii) expenditures under the Medicare program, including any 
     reduced expenditures under Part A of title XVIII of such Act 
     that are attributable to the improvement in the delivery of 
     inpatient hospital services by reason of such hospital value-
     based purchasing program;
       (iii) the quality performance among safety net hospitals 
     and any barriers such hospitals face in meeting the 
     performance standards applicable under such hospital value-
     based purchasing program; and
       (iv) the quality performance among small rural and small 
     urban hospitals and any barriers such hospitals face in 
     meeting the performance standards applicable under such 
     hospital value-based purchasing program.
       (B) Reports.--
       (i) Interim report.--Not later than October 1, 2015, the 
     Comptroller General of the United States shall submit to 
     Congress an interim report containing the results of the 
     study conducted under subparagraph (A), together with 
     recommendations for such legislation and administrative 
     action as the Comptroller General determines appropriate.
       (ii) Final report.--Not later than July 1, 2017, the 
     Comptroller General of the United States shall submit to 
     Congress a report containing the results of the study 
     conducted under subparagraph (A), together with 
     recommendations for such legislation and administrative 
     action as the Comptroller General determines appropriate.
       (5) HHS study and report.--
       (A) Study.--The Secretary of Health and Human Services 
     shall conduct a study on the performance of the hospital 
     value-based purchasing program established under section 
     1886(o) of the Social Security Act, as added by paragraph 
     (1). Such study shall include an analysis--
       (i) of ways to improve the hospital value-based purchasing 
     program and ways to address any unintended consequences that 
     may occur as a result of such program;
       (ii) of whether the hospital value-based purchasing program 
     resulted in lower spending under the Medicare program under 
     title XVIII of such Act or other financial savings to 
     hospitals;
       (iii) the appropriateness of the Medicare program sharing 
     in any savings generated through the hospital value-based 
     purchasing program; and
       (iv) any other area determined appropriate by the 
     Secretary.
       (B) Report.--Not later than January 1, 2016, the Secretary 
     of Health and Human Services shall submit to Congress a 
     report containing the results of the study conducted under 
     subparagraph (A), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.
       (b) Value-Based Purchasing Demonstration Programs.--
       (1) Value-based purchasing demonstration program for 
     inpatient critical access hospitals.--
       (A) Establishment.--
       (i) In general.--Not later than 2 years after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services (in this subsection referred to as the 
     ``Secretary'') shall establish a demonstration program under 
     which the Secretary establishes a value-based purchasing 
     program under the Medicare program under title XVIII of the 
     Social Security Act for critical access hospitals (as defined 
     in paragraph (1) of section 1861(mm) of such Act (42 U.S.C. 
     1395x(mm))) with respect to inpatient critical access 
     hospital services (as defined in paragraph (2) of such 
     section) in order to test innovative methods of measuring and 
     rewarding quality and efficient health care furnished by such 
     hospitals.
       (ii) Duration.--The demonstration program under this 
     paragraph shall be conducted for a 3-year period.
       (iii) Sites.--The Secretary shall conduct the demonstration 
     program under this paragraph at an appropriate number (as 
     determined by the Secretary) of critical access hospitals. 
     The Secretary shall ensure that such hospitals are 
     representative of the spectrum of such hospitals that 
     participate in the Medicare program.
       (B) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act as may be necessary to carry out the demonstration 
     program under this paragraph.
       (C) Budget neutrality requirement.--In conducting the 
     demonstration program under this section, the Secretary shall 
     ensure that the aggregate payments made by the Secretary do 
     not exceed the amount which the Secretary would have paid if 
     the demonstration program under this section was not 
     implemented.
       (D) Report.--Not later than 18 months after the completion 
     of the demonstration program under this paragraph, the 
     Secretary shall submit to Congress a report on the 
     demonstration program together with--
       (i) recommendations on the establishment of a permanent 
     value-based purchasing program under the Medicare program for 
     critical access hospitals with respect to inpatient critical 
     access hospital services; and
       (ii) recommendations for such other legislation and 
     administrative action as the Secretary determines 
     appropriate.
       (2) Value-based purchasing demonstration program for 
     hospitals excluded from hospital value-based purchasing 
     program as a result of insufficient numbers of measures and 
     cases.--
       (A) Establishment.--
       (i) In general.--Not later than 2 years after the date of 
     enactment of this Act, the Secretary shall establish a 
     demonstration program under which the Secretary establishes a 
     value-based purchasing program under the Medicare program 
     under title XVIII of the Social Security Act for applicable 
     hospitals (as defined in clause (ii)) with respect to 
     inpatient hospital services (as defined in section 1861(b) of 
     the Social Security Act (42 U.S.C. 1395x(b))) in order to 
     test innovative methods of measuring and rewarding quality 
     and efficient health care furnished by such hospitals.
       (ii) Applicable hospital defined.--For purposes of this 
     paragraph, the term ``applicable hospital'' means a hospital 
     described in subclause (III) or (IV) of section 
     1886(o)(1)(C)(ii) of the Social Security Act, as added by 
     subsection (a)(1).

[[Page 4269]]

       (iii) Duration.--The demonstration program under this 
     paragraph shall be conducted for a 3-year period.
       (iv) Sites.--The Secretary shall conduct the demonstration 
     program under this paragraph at an appropriate number (as 
     determined by the Secretary) of applicable hospitals. The 
     Secretary shall ensure that such hospitals are representative 
     of the spectrum of such hospitals that participate in the 
     Medicare program.
       (B) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act as may be necessary to carry out the demonstration 
     program under this paragraph.
       (C) Budget neutrality requirement.--In conducting the 
     demonstration program under this section, the Secretary shall 
     ensure that the aggregate payments made by the Secretary do 
     not exceed the amount which the Secretary would have paid if 
     the demonstration program under this section was not 
     implemented.
       (D) Report.--Not later than 18 months after the completion 
     of the demonstration program under this paragraph, the 
     Secretary shall submit to Congress a report on the 
     demonstration program together with--
       (i) recommendations on the establishment of a permanent 
     value-based purchasing program under the Medicare program for 
     applicable hospitals with respect to inpatient hospital 
     services; and
       (ii) recommendations for such other legislation and 
     administrative action as the Secretary determines 
     appropriate.

     SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING 
                   SYSTEM.

       (a) Extension.--Section 1848(m) of the Social Security Act 
     (42 U.S.C. 1395w-4(m)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (A), in the matter preceding clause 
     (i), by striking ``2010'' and inserting ``2014''; and
       (B) in subparagraph (B)--
       (i) in clause (i), by striking ``and'' at the end;
       (ii) in clause (ii), by striking the period at the end and 
     inserting a semicolon; and
       (iii) by adding at the end the following new clauses:
       ``(iii) for 2011, 1.0 percent; and
       ``(iv) for 2012, 2013, and 2014, 0.5 percent.'';
       (2) in paragraph (3)--
       (A) in subparagraph (A), in the matter preceding clause 
     (i), by inserting ``(or, for purposes of subsection (a)(8), 
     for the quality reporting period for the year)'' after 
     ``reporting period''; and
       (B) in subparagraph (C)(i), by inserting ``, or, for 
     purposes of subsection (a)(8), for a quality reporting period 
     for the year'' after ``(a)(5), for a reporting period for a 
     year'';
       (3) in paragraph (5)(E)(iv), by striking ``subsection 
     (a)(5)(A)'' and inserting ``paragraphs (5)(A) and (8)(A) of 
     subsection (a)''; and
       (4) in paragraph (6)(C)--
       (A) in clause (i)(II), by striking ``, 2009, 2010, and 
     2011'' and inserting ``and subsequent years''; and
       (B) in clause (iii)--
       (i) by inserting ``(a)(8)'' after ``(a)(5)''; and
       (ii) by striking ``under subparagraph (D)(iii) of such 
     subsection'' and inserting ``under subsection (a)(5)(D)(iii) 
     or the quality reporting period under subsection 
     (a)(8)(D)(iii), respectively''.
       (b) Incentive Payment Adjustment for Quality Reporting.--
     Section 1848(a) of the Social Security Act (42 U.S.C. 1395w-
     4(a)) is amended by adding at the end the following new 
     paragraph:
       ``(8) Incentives for quality reporting.--
       ``(A) Adjustment.--
       ``(i) In general.--With respect to covered professional 
     services furnished by an eligible professional during 2015 or 
     any subsequent year, if the eligible professional does not 
     satisfactorily submit data on quality measures for covered 
     professional services for the quality reporting period for 
     the year (as determined under subsection (m)(3)(A)), the fee 
     schedule amount for such services furnished by such 
     professional during the year (including the fee schedule 
     amount for purposes of determining a payment based on such 
     amount) shall be equal to the applicable percent of the fee 
     schedule amount that would otherwise apply to such services 
     under this subsection (determined after application of 
     paragraphs (3), (5), and (7), but without regard to this 
     paragraph).
       ``(ii) Applicable percent.--For purposes of clause (i), the 
     term `applicable percent' means--

       ``(I) for 2015, 98.5 percent; and
       ``(II) for 2016 and each subsequent year, 98 percent.

       ``(B) Application.--
       ``(i) Physician reporting system rules.--Paragraphs (5), 
     (6), and (8) of subsection (k) shall apply for purposes of 
     this paragraph in the same manner as they apply for purposes 
     of such subsection.
       ``(ii) Incentive payment validation rules.--Clauses (ii) 
     and (iii) of subsection (m)(5)(D) shall apply for purposes of 
     this paragraph in a similar manner as they apply for purposes 
     of such subsection.
       ``(C) Definitions.--For purposes of this paragraph:
       ``(i) Eligible professional; covered professional 
     services.--The terms `eligible professional' and `covered 
     professional services' have the meanings given such terms in 
     subsection (k)(3).
       ``(ii) Physician reporting system.--The term `physician 
     reporting system' means the system established under 
     subsection (k).
       ``(iii) Quality reporting period.--The term `quality 
     reporting period' means, with respect to a year, a period 
     specified by the Secretary.''.
       (c) Maintenance of Certification Programs.--
       (1) In general.--Section 1848(k)(4) of the Social Security 
     Act (42 U.S.C. 1395w-4(k)(4)) is amended by inserting ``or 
     through a Maintenance of Certification program operated by a 
     specialty body of the American Board of Medical Specialties 
     that meets the criteria for such a registry'' after 
     ``Database)''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply for years after 2010.
       (d) Integration of Physician Quality Reporting and EHR 
     Reporting.--Section 1848(m) of the Social Security Act (42 
     U.S.C. 1395w-4(m)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Integration of physician quality reporting and ehr 
     reporting.--Not later than January 1, 2012, the Secretary 
     shall develop a plan to integrate reporting on quality 
     measures under this subsection with reporting requirements 
     under subsection (o) relating to the meaningful use of 
     electronic health records. Such integration shall consist of 
     the following:
       ``(A) The selection of measures, the reporting of which 
     would both demonstrate--
       ``(i) meaningful use of an electronic health record for 
     purposes of subsection (o); and
       ``(ii) quality of care furnished to an individual.
       ``(B) Such other activities as specified by the 
     Secretary.''.
       (e) Feedback.--Section 1848(m)(5) of the Social Security 
     Act (42 U.S.C. 1395w-4(m)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(H) Feedback.--The Secretary shall provide timely 
     feedback to eligible professionals on the performance of the 
     eligible professional with respect to satisfactorily 
     submitting data on quality measures under this subsection.''.
       (f) Appeals.--Such section is further amended--
       (1) in subparagraph (E), by striking ``There shall'' and 
     inserting ``Except as provided in subparagraph (I), there 
     shall''; and
       (2) by adding at the end the following new subparagraph:
       ``(I) Informal appeals process.--The Secretary shall, by 
     not later than January 1, 2011, establish and have in place 
     an informal process for eligible professionals to seek a 
     review of the determination that an eligible professional did 
     not satisfactorily submit data on quality measures under this 
     subsection.''.

     SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM.

       (a) In General.--Section 1848(n) of the Social Security Act 
     (42 U.S.C. 1395w-4(n)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (A)--
       (i) by striking ``general.--The Secretary'' and inserting 
     ``general.--
       ``(i) Establishment.--The Secretary'';
       (ii) in clause (i), as added by clause (i), by striking 
     ``the `Program')'' and all that follows through the period at 
     the end of the second sentence and inserting ``the 
     `Program').''; and
       (iii) by adding at the end the following new clauses:
       ``(ii) Reports on resources.--The Secretary shall use 
     claims data under this title (and may use other data) to 
     provide confidential reports to physicians (and, as 
     determined appropriate by the Secretary, to groups of 
     physicians) that measure the resources involved in furnishing 
     care to individuals under this title.
       ``(iii) Inclusion of certain information.--If determined 
     appropriate by the Secretary, the Secretary may include 
     information on the quality of care furnished to individuals 
     under this title by the physician (or group of physicians) in 
     such reports.''; and
       (B) in subparagraph (B), by striking ``subparagraph (A)'' 
     and inserting ``subparagraph (A)(ii)'';
       (2) in paragraph (4)--
       (A) in the heading, by inserting ``initial'' after 
     ``focus''; and
       (B) in the matter preceding subparagraph (A), by inserting 
     ``initial'' after ``focus the'';
       (3) in paragraph (6), by adding at the end the following 
     new sentence: ``For adjustments for reports on utilization 
     under paragraph (9), see subparagraph (D) of such 
     paragraph.''; and
       (4) by adding at the end the following new paragraphs:
       ``(9) Reports on utilization.--
       ``(A) Development of episode grouper.--
       ``(i) In general.--The Secretary shall develop an episode 
     grouper that combines separate but clinically related items 
     and services into an episode of care for an individual, as 
     appropriate.
       ``(ii) Timeline for development.--The episode grouper 
     described in subparagraph (A) shall be developed by not later 
     than January 1, 2012.
       ``(iii) Public availability.--The Secretary shall make the 
     details of the episode grouper described in subparagraph (A) 
     available to the public.
       ``(iv) Endorsement.--The Secretary shall seek endorsement 
     of the episode grouper described in subparagraph (A) by the 
     entity with a contract under section 1890(a).
       ``(B) Reports on utilization.--Effective beginning with 
     2012, the Secretary shall provide reports to physicians that 
     compare, as determined appropriate by the Secretary, patterns 
     of resource use of the individual physician to such patterns 
     of other physicians.
       ``(C) Analysis of data.--The Secretary shall, for purposes 
     of preparing reports under this

[[Page 4270]]

     paragraph, establish methodologies as appropriate, such as 
     to--
       ``(i) attribute episodes of care, in whole or in part, to 
     physicians;
       ``(ii) identify appropriate physicians for purposes of 
     comparison under subparagraph (B); and
       ``(iii) aggregate episodes of care attributed to a 
     physician under clause (i) into a composite measure per 
     individual.
       ``(D) Data adjustment.--In preparing reports under this 
     paragraph, the Secretary shall make appropriate adjustments, 
     including adjustments--
       ``(i) to account for differences in socioeconomic and 
     demographic characteristics, ethnicity, and health status of 
     individuals (such as to recognize that less healthy 
     individuals may require more intensive interventions); and
       ``(ii) to eliminate the effect of geographic adjustments in 
     payment rates (as described in subsection (e)).
       ``(E) Public availability of methodology.--The Secretary 
     shall make available to the public--
       ``(i) the methodologies established under subparagraph (C);
       ``(ii) information regarding any adjustments made to data 
     under subparagraph (D); and
       ``(iii) aggregate reports with respect to physicians.
       ``(F) Definition of physician.--In this paragraph:
       ``(i) In general.--The term `physician' has the meaning 
     given that term in section 1861(r)(1).
       ``(ii) Treatment of groups.--Such term includes, as the 
     Secretary determines appropriate, a group of physicians.
       ``(G) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the establishment of the methodology 
     under subparagraph (C), including the determination of an 
     episode of care under such methodology.
       ``(10) Coordination with other value-based purchasing 
     reforms.--The Secretary shall coordinate the Program with the 
     value-based payment modifier established under subsection (p) 
     and, as the Secretary determines appropriate, other similar 
     provisions of this title.''.
       (b) Conforming Amendment.--Section 1890(b) of the Social 
     Security Act (42 U.S.C. 1395aaa(b)) is amended by adding at 
     the end the following new paragraph:
       ``(6) Review and endorsement of episode grouper under the 
     physician feedback program.--The entity shall provide for the 
     review and, as appropriate, the endorsement of the episode 
     grouper developed by the Secretary under section 
     1848(n)(9)(A). Such review shall be conducted on an expedited 
     basis.''.

     SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS, 
                   INPATIENT REHABILITATION HOSPITALS, AND HOSPICE 
                   PROGRAMS.

       (a) Long-term Care Hospitals.--Section 1886(m) of the 
     Social Security Act (42 U.S.C. 1395ww(m)), as amended by 
     section 3401(c), is amended by adding at the end the 
     following new paragraph:
       ``(5) Quality reporting.--
       ``(A) Reduction in update for failure to report.--
       ``(i) In general.--Under the system described in paragraph 
     (1), for rate year 2014 and each subsequent rate year, in the 
     case of a long-term care hospital that does not submit data 
     to the Secretary in accordance with subparagraph (C) with 
     respect to such a rate year, any annual update to a standard 
     Federal rate for discharges for the hospital during the rate 
     year, and after application of paragraph (3), shall be 
     reduced by 2 percentage points.
       ``(ii) Special rule.--The application of this subparagraph 
     may result in such annual update being less than 0.0 for a 
     rate year, and may result in payment rates under the system 
     described in paragraph (1) for a rate year being less than 
     such payment rates for the preceding rate year.
       ``(B) Noncumulative application.--Any reduction under 
     subparagraph (A) shall apply only with respect to the rate 
     year involved and the Secretary shall not take into account 
     such reduction in computing the payment amount under the 
     system described in paragraph (1) for a subsequent rate year.
       ``(C) Submission of quality data.--For rate year 2014 and 
     each subsequent rate year, each long-term care hospital shall 
     submit to the Secretary data on quality measures specified 
     under subparagraph (D). Such data shall be submitted in a 
     form and manner, and at a time, specified by the Secretary 
     for purposes of this subparagraph.
       ``(D) Quality measures.--
       ``(i) In general.--Subject to clause (ii), any measure 
     specified by the Secretary under this subparagraph must have 
     been endorsed by the entity with a contract under section 
     1890(a).
       ``(ii) Exception.--In the case of a specified area or 
     medical topic determined appropriate by the Secretary for 
     which a feasible and practical measure has not been endorsed 
     by the entity with a contract under section 1890(a), the 
     Secretary may specify a measure that is not so endorsed as 
     long as due consideration is given to measures that have been 
     endorsed or adopted by a consensus organization identified by 
     the Secretary.
       ``(iii) Time frame.--Not later than October 1, 2012, the 
     Secretary shall publish the measures selected under this 
     subparagraph that will be applicable with respect to rate 
     year 2014.
       ``(E) Public availability of data submitted.--The Secretary 
     shall establish procedures for making data submitted under 
     subparagraph (C) available to the public. Such procedures 
     shall ensure that a long-term care hospital has the 
     opportunity to review the data that is to be made public with 
     respect to the hospital prior to such data being made public. 
     The Secretary shall report quality measures that relate to 
     services furnished in inpatient settings in long-term care 
     hospitals on the Internet website of the Centers for Medicare 
     & Medicaid Services.''.
       (b) Inpatient Rehabilitation Hospitals.--Section 1886(j) of 
     the Social Security Act (42 U.S.C. 1395ww(j)) is amended--
       (1) by redesignating paragraph (7) as paragraph (8); and
       (2) by inserting after paragraph (6) the following new 
     paragraph:
       ``(7) Quality reporting.--
       ``(A) Reduction in update for failure to report.--
       ``(i) In general.--For purposes of fiscal year 2014 and 
     each subsequent fiscal year, in the case of a rehabilitation 
     facility that does not submit data to the Secretary in 
     accordance with subparagraph (C) with respect to such a 
     fiscal year, after determining the increase factor described 
     in paragraph (3)(C), and after application of paragraph 
     (3)(D), the Secretary shall reduce such increase factor for 
     payments for discharges occurring during such fiscal year by 
     2 percentage points.
       ``(ii) Special rule.--The application of this subparagraph 
     may result in the increase factor described in paragraph 
     (3)(C) being less than 0.0 for a fiscal year, and may result 
     in payment rates under this subsection for a fiscal year 
     being less than such payment rates for the preceding fiscal 
     year.
       ``(B) Noncumulative application.--Any reduction under 
     subparagraph (A) shall apply only with respect to the fiscal 
     year involved and the Secretary shall not take into account 
     such reduction in computing the payment amount under this 
     subsection for a subsequent fiscal year.
       ``(C) Submission of quality data.--For fiscal year 2014 and 
     each subsequent rate year, each rehabilitation facility shall 
     submit to the Secretary data on quality measures specified 
     under subparagraph (D). Such data shall be submitted in a 
     form and manner, and at a time, specified by the Secretary 
     for purposes of this subparagraph.
       ``(D) Quality measures.--
       ``(i) In general.--Subject to clause (ii), any measure 
     specified by the Secretary under this subparagraph must have 
     been endorsed by the entity with a contract under section 
     1890(a).
       ``(ii) Exception.--In the case of a specified area or 
     medical topic determined appropriate by the Secretary for 
     which a feasible and practical measure has not been endorsed 
     by the entity with a contract under section 1890(a), the 
     Secretary may specify a measure that is not so endorsed as 
     long as due consideration is given to measures that have been 
     endorsed or adopted by a consensus organization identified by 
     the Secretary.
       ``(iii) Time frame.--Not later than October 1, 2012, the 
     Secretary shall publish the measures selected under this 
     subparagraph that will be applicable with respect to fiscal 
     year 2014.
       ``(E) Public availability of data submitted.--The Secretary 
     shall establish procedures for making data submitted under 
     subparagraph (C) available to the public. Such procedures 
     shall ensure that a rehabilitation facility has the 
     opportunity to review the data that is to be made public with 
     respect to the facility prior to such data being made public. 
     The Secretary shall report quality measures that relate to 
     services furnished in inpatient settings in rehabilitation 
     facilities on the Internet website of the Centers for 
     Medicare & Medicaid Services.''.
       (c) Hospice Programs.--Section 1814(i) of the Social 
     Security Act (42 U.S.C. 1395f(i)) is amended--
       (1) by redesignating paragraph (5) as paragraph (6); and
       (2) by inserting after paragraph (4) the following new 
     paragraph:
       ``(5) Quality reporting.--
       ``(A) Reduction in update for failure to report.--
       ``(i) In general.--For purposes of fiscal year 2014 and 
     each subsequent fiscal year, in the case of a hospice program 
     that does not submit data to the Secretary in accordance with 
     subparagraph (C) with respect to such a fiscal year, after 
     determining the market basket percentage increase under 
     paragraph (1)(C)(ii)(VII) or paragraph (1)(C)(iii), as 
     applicable, and after application of paragraph (1)(C)(iv), 
     with respect to the fiscal year, the Secretary shall reduce 
     such market basket percentage increase by 2 percentage 
     points.
       ``(ii) Special rule.--The application of this subparagraph 
     may result in the market basket percentage increase under 
     paragraph (1)(C)(ii)(VII) or paragraph (1)(C)(iii), as 
     applicable, being less than 0.0 for a fiscal year, and may 
     result in payment rates under this subsection for a fiscal 
     year being less than such payment rates for the preceding 
     fiscal year.
       ``(B) Noncumulative application.--Any reduction under 
     subparagraph (A) shall apply only with respect to the fiscal 
     year involved and the Secretary shall not take into account 
     such reduction in computing the payment amount under this 
     subsection for a subsequent fiscal year.
       ``(C) Submission of quality data.--For fiscal year 2014 and 
     each subsequent fiscal year, each hospice program shall 
     submit to the Secretary data on quality measures specified 
     under subparagraph (D). Such data shall be submitted

[[Page 4271]]

     in a form and manner, and at a time, specified by the 
     Secretary for purposes of this subparagraph.
       ``(D) Quality measures.--
       ``(i) In general.--Subject to clause (ii), any measure 
     specified by the Secretary under this subparagraph must have 
     been endorsed by the entity with a contract under section 
     1890(a).
       ``(ii) Exception.--In the case of a specified area or 
     medical topic determined appropriate by the Secretary for 
     which a feasible and practical measure has not been endorsed 
     by the entity with a contract under section 1890(a), the 
     Secretary may specify a measure that is not so endorsed as 
     long as due consideration is given to measures that have been 
     endorsed or adopted by a consensus organization identified by 
     the Secretary.
       ``(iii) Time frame.--Not later than October 1, 2012, the 
     Secretary shall publish the measures selected under this 
     subparagraph that will be applicable with respect to fiscal 
     year 2014.
       ``(E) Public availability of data submitted.--The Secretary 
     shall establish procedures for making data submitted under 
     subparagraph (C) available to the public. Such procedures 
     shall ensure that a hospice program has the opportunity to 
     review the data that is to be made public with respect to the 
     hospice program prior to such data being made public. The 
     Secretary shall report quality measures that relate to 
     hospice care provided by hospice programs on the Internet 
     website of the Centers for Medicare & Medicaid Services.''.

     SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOSPITALS.

       Section 1866 of the Social Security Act (42 U.S.C. 1395cc) 
     is amended--
       (1) in subsection (a)(1)--
       (A) in subparagraph (U), by striking ``and'' at the end;
       (B) in subparagraph (V), by striking the period at the end 
     and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(W) in the case of a hospital described in section 
     1886(d)(1)(B)(v), to report quality data to the Secretary in 
     accordance with subsection (k).''; and
       (2) by adding at the end the following new subsection:
       ``(k) Quality Reporting by Cancer Hospitals.--
       ``(1) In general.--For purposes of fiscal year 2014 and 
     each subsequent fiscal year, a hospital described in section 
     1886(d)(1)(B)(v) shall submit data to the Secretary in 
     accordance with paragraph (2) with respect to such a fiscal 
     year.
       ``(2) Submission of quality data.--For fiscal year 2014 and 
     each subsequent fiscal year, each hospital described in such 
     section shall submit to the Secretary data on quality 
     measures specified under paragraph (3). Such data shall be 
     submitted in a form and manner, and at a time, specified by 
     the Secretary for purposes of this subparagraph.
       ``(3) Quality measures.--
       ``(A) In general.--Subject to subparagraph (B), any measure 
     specified by the Secretary under this paragraph must have 
     been endorsed by the entity with a contract under section 
     1890(a).
       ``(B) Exception.--In the case of a specified area or 
     medical topic determined appropriate by the Secretary for 
     which a feasible and practical measure has not been endorsed 
     by the entity with a contract under section 1890(a), the 
     Secretary may specify a measure that is not so endorsed as 
     long as due consideration is given to measures that have been 
     endorsed or adopted by a consensus organization identified by 
     the Secretary.
       ``(C) Time frame.--Not later than October 1, 2012, the 
     Secretary shall publish the measures selected under this 
     paragraph that will be applicable with respect to fiscal year 
     2014.
       ``(4) Public availability of data submitted.--The Secretary 
     shall establish procedures for making data submitted under 
     paragraph (4) available to the public. Such procedures shall 
     ensure that a hospital described in section 1886(d)(1)(B)(v) 
     has the opportunity to review the data that is to be made 
     public with respect to the hospital prior to such data being 
     made public. The Secretary shall report quality measures of 
     process, structure, outcome, patients' perspective on care, 
     efficiency, and costs of care that relate to services 
     furnished in such hospitals on the Internet website of the 
     Centers for Medicare & Medicaid Services.''.

     SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR 
                   SKILLED NURSING FACILITIES AND HOME HEALTH 
                   AGENCIES.

       (a) Skilled Nursing Facilities.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     develop a plan to implement a value-based purchasing program 
     for payments under the Medicare program under title XVIII of 
     the Social Security Act for skilled nursing facilities (as 
     defined in section 1819(a) of such Act (42 U.S.C. 1395i-
     3(a))).
       (2) Details.--In developing the plan under paragraph (1), 
     the Secretary shall consider the following issues:
       (A) The ongoing development, selection, and modification 
     process for measures (including under section 1890 of the 
     Social Security Act (42 U.S.C. 1395aaa) and section 1890A 
     such Act, as added by section 3014), to the extent feasible 
     and practicable, of all dimensions of quality and efficiency 
     in skilled nursing facilities.
       (i) In general.--Subject to clause (ii), any measure 
     specified by the Secretary under subparagraph (A)(iii) must 
     have been endorsed by the entity with a contract under 
     section 1890(a).
       (ii) Exception.--In the case of a specified area or medical 
     topic determined appropriate by the Secretary for which a 
     feasible and practical measure has not been endorsed by the 
     entity with a contract under section 1890(a), the Secretary 
     may specify a measure that is not so endorsed as long as due 
     consideration is given to measures that have been endorsed or 
     adopted by a consensus organization identified by the 
     Secretary.
       (B) The reporting, collection, and validation of quality 
     data.
       (C) The structure of value-based payment adjustments, 
     including the determination of thresholds or improvements in 
     quality that would substantiate a payment adjustment, the 
     size of such payments, and the sources of funding for the 
     value-based bonus payments.
       (D) Methods for the public disclosure of information on the 
     performance of skilled nursing facilities.
       (E) Any other issues determined appropriate by the 
     Secretary.
       (3) Consultation.--In developing the plan under paragraph 
     (1), the Secretary shall--
       (A) consult with relevant affected parties; and
       (B) consider experience with such demonstrations that the 
     Secretary determines are relevant to the value-based 
     purchasing program described in paragraph (1).
       (4) Report to congress.--Not later than October 1, 2011, 
     the Secretary shall submit to Congress a report containing 
     the plan developed under paragraph (1).
       (b) Home Health Agencies.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     develop a plan to implement a value-based purchasing program 
     for payments under the Medicare program under title XVIII of 
     the Social Security Act for home health agencies (as defined 
     in section 1861(o) of such Act (42 U.S.C. 1395x(o))).
       (2) Details.--In developing the plan under paragraph (1), 
     the Secretary shall consider the following issues:
       (A) The ongoing development, selection, and modification 
     process for measures (including under section 1890 of the 
     Social Security Act (42 U.S.C. 1395aaa) and section 1890A 
     such Act, as added by section 3014), to the extent feasible 
     and practicable, of all dimensions of quality and efficiency 
     in home health agencies.
       (B) The reporting, collection, and validation of quality 
     data.
       (C) The structure of value-based payment adjustments, 
     including the determination of thresholds or improvements in 
     quality that would substantiate a payment adjustment, the 
     size of such payments, and the sources of funding for the 
     value-based bonus payments.
       (D) Methods for the public disclosure of information on the 
     performance of home health agencies.
       (E) Any other issues determined appropriate by the 
     Secretary.
       (3) Consultation.--In developing the plan under paragraph 
     (1), the Secretary shall--
       (A) consult with relevant affected parties; and
       (B) consider experience with such demonstrations that the 
     Secretary determines are relevant to the value-based 
     purchasing program described in paragraph (1).
       (4) Report to congress.--Not later than October 1, 2011, 
     the Secretary shall submit to Congress a report containing 
     the plan developed under paragraph (1).

     SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN 
                   FEE SCHEDULE.

       Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) 
     is amended--
       (1) in subsection (b)(1), by inserting ``subject to 
     subsection (p),'' after ``1998,''; and
       (2) by adding at the end the following new subsection:
       ``(p) Establishment of Value-based Payment Modifier.--
       ``(1) In general.--The Secretary shall establish a payment 
     modifier that provides for differential payment to a 
     physician or a group of physicians under the fee schedule 
     established under subsection (b) based upon the quality of 
     care furnished compared to cost (as determined under 
     paragraphs (2) and (3), respectively) during a performance 
     period. Such payment modifier shall be separate from the 
     geographic adjustment factors established under subsection 
     (e).
       ``(2) Quality.--
       ``(A) In general.--For purposes of paragraph (1), quality 
     of care shall be evaluated, to the extent practicable, based 
     on a composite of measures of the quality of care furnished 
     (as established by the Secretary under subparagraph (B)).
       ``(B) Measures.--
       ``(i) The Secretary shall establish appropriate measures of 
     the quality of care furnished by a physician or group of 
     physicians to individuals enrolled under this part, such as 
     measures that reflect health outcomes. Such measures shall be 
     risk adjusted as determined appropriate by the Secretary.
       ``(ii) The Secretary shall seek endorsement of the measures 
     established under this subparagraph by the entity with a 
     contract under section 1890(a).
       ``(3) Costs.--For purposes of paragraph (1), costs shall be 
     evaluated, to the extent practicable, based on a composite of 
     appropriate measures of costs established by the Secretary 
     (such as the composite measure under the methodology 
     established under subsection (n)(9)(C)(iii)) that eliminate 
     the effect of geographic adjustments in payment rates (as 
     described in subsection (e)), and take into account

[[Page 4272]]

     risk factors (such as socioeconomic and demographic 
     characteristics, ethnicity, and health status of individuals 
     (such as to recognize that less healthy individuals may 
     require more intensive interventions) and other factors 
     determined appropriate by the Secretary.
       ``(4) Implementation.--
       ``(A) Publication of measures, dates of implementation, 
     performance period.--Not later than January 1, 2012, the 
     Secretary shall publish the following:
       ``(i) The measures of quality of care and costs established 
     under paragraphs (2) and (3), respectively.
       ``(ii) The dates for implementation of the payment modifier 
     (as determined under subparagraph (B)).
       ``(iii) The initial performance period (as specified under 
     subparagraph (B)(ii)).
       ``(B) Deadlines for implementation.--
       ``(i) Initial implementation.--Subject to the preceding 
     provisions of this subparagraph, the Secretary shall begin 
     implementing the payment modifier established under this 
     subsection through the rulemaking process during 2013 for the 
     physician fee schedule established under subsection (b).
       ``(ii) Initial performance period.--

       ``(I) In general.--The Secretary shall specify an initial 
     performance period for application of the payment modifier 
     established under this subsection with respect to 2015.
       ``(II) Provision of information during initial performance 
     period.--During the initial performance period, the Secretary 
     shall, to the extent practicable, provide information to 
     physicians and groups of physicians about the quality of care 
     furnished by the physician or group of physicians to 
     individuals enrolled under this part compared to cost (as 
     determined under paragraphs (2) and (3), respectively) with 
     respect to the performance period.

       ``(iii) Application.--The Secretary shall apply the payment 
     modifier established under this subsection for items and 
     services furnished--

       ``(I) beginning on January 1, 2015, with respect to 
     specific physicians and groups of physicians the Secretary 
     determines appropriate; and
       ``(II) beginning not later than January 1, 2017, with 
     respect to all physicians and groups of physicians.

       ``(C) Budget neutrality.--The payment modifier established 
     under this subsection shall be implemented in a budget 
     neutral manner.
       ``(5) Systems-based care.--The Secretary shall, as 
     appropriate, apply the payment modifier established under 
     this subsection in a manner that promotes systems-based care.
       ``(6) Consideration of special circumstances of certain 
     providers.--In applying the payment modifier under this 
     subsection, the Secretary shall, as appropriate, take into 
     account the special circumstances of physicians or groups of 
     physicians in rural areas and other underserved communities.
       ``(7) Application.--For purposes of the initial application 
     of the payment modifier established under this subsection 
     during the period beginning on January 1, 2015, and ending on 
     December 31, 2016, the term `physician' has the meaning given 
     such term in section 1861(r). On or after January 1, 2017, 
     the Secretary may apply this subsection to eligible 
     professionals (as defined in subsection (k)(3)(B)) as the 
     Secretary determines appropriate.
       ``(8) Definitions.--For purposes of this subsection:
       ``(A) Costs.--The term `costs' means expenditures per 
     individual as determined appropriate by the Secretary. In 
     making the determination under the preceding sentence, the 
     Secretary may take into account the amount of growth in 
     expenditures per individual for a physician compared to the 
     amount of such growth for other physicians.
       ``(B) Performance period.--The term `performance period' 
     means a period specified by the Secretary.
       ``(9) Coordination with other value-based purchasing 
     reforms.--The Secretary shall coordinate the value-based 
     payment modifier established under this subsection with the 
     Physician Feedback Program under subsection (n) and, as the 
     Secretary determines appropriate, other similar provisions of 
     this title.
       ``(10) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(A) the establishment of the value-based payment modifier 
     under this subsection;
       ``(B) the evaluation of quality of care under paragraph 
     (2), including the establishment of appropriate measures of 
     the quality of care under paragraph (2)(B);
       ``(C) the evaluation of costs under paragraph (3), 
     including the establishment of appropriate measures of costs 
     under such paragraph;
       ``(D) the dates for implementation of the value-based 
     payment modifier;
       ``(E) the specification of the initial performance period 
     and any other performance period under paragraphs (4)(B)(ii) 
     and (8)(B), respectively;
       ``(F) the application of the value-based payment modifier 
     under paragraph (7); and
       ``(G) the determination of costs under paragraph (8)(A).''.

     SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN 
                   HOSPITALS.

       (a) In General.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww), as amended by section 3001, is amended by 
     adding at the end the following new subsection:
       ``(p) Adjustment to Hospital Payments for Hospital Acquired 
     Conditions.--
       ``(1) In general.--In order to provide an incentive for 
     applicable hospitals to reduce hospital acquired conditions 
     under this title, with respect to discharges from an 
     applicable hospital occurring during fiscal year 2015 or a 
     subsequent fiscal year, the amount of payment under this 
     section or section 1814(b)(3), as applicable, for such 
     discharges during the fiscal year shall be equal to 99 
     percent of the amount of payment that would otherwise apply 
     to such discharges under this section or section 1814(b)(3) 
     (determined after the application of subsections (o) and (q) 
     and section 1814(l)(4) but without regard to this 
     subsection).
       ``(2) Applicable hospitals.--
       ``(A) In general.--For purposes of this subsection, the 
     term `applicable hospital' means a subsection (d) hospital 
     that meets the criteria described in subparagraph (B).
       ``(B) Criteria described.--
       ``(i) In general.--The criteria described in this 
     subparagraph, with respect to a subsection (d) hospital, is 
     that the subsection (d) hospital is in the top quartile of 
     all subsection (d) hospitals, relative to the national 
     average, of hospital acquired conditions during the 
     applicable period, as determined by the Secretary.
       ``(ii) Risk adjustment.--In carrying out clause (i), the 
     Secretary shall establish and apply an appropriate risk 
     adjustment methodology.
       ``(C) Exemption.--In the case of a hospital that is paid 
     under section 1814(b)(3), the Secretary may exempt such 
     hospital from the application of this subsection if the State 
     which is paid under such section submits an annual report to 
     the Secretary describing how a similar program in the State 
     for a participating hospital or hospitals achieves or 
     surpasses the measured results in terms of patient health 
     outcomes and cost savings established under this subsection.
       ``(3) Hospital acquired conditions.--For purposes of this 
     subsection, the term `hospital acquired condition' means a 
     condition identified for purposes of subsection (d)(4)(D)(iv) 
     and any other condition determined appropriate by the 
     Secretary that an individual acquires during a stay in an 
     applicable hospital, as determined by the Secretary.
       ``(4) Applicable period.--In this subsection, the term 
     `applicable period' means, with respect to a fiscal year, a 
     period specified by the Secretary.
       ``(5) Reporting to hospitals.--Prior to fiscal year 2015 
     and each subsequent fiscal year, the Secretary shall provide 
     confidential reports to applicable hospitals with respect to 
     hospital acquired conditions of the applicable hospital 
     during the applicable period.
       ``(6) Reporting hospital specific information.--
       ``(A) In general.--The Secretary shall make information 
     available to the public regarding hospital acquired 
     conditions of each applicable hospital.
       ``(B) Opportunity to review and submit corrections.--The 
     Secretary shall ensure that an applicable hospital has the 
     opportunity to review, and submit corrections for, the 
     information to be made public with respect to the hospital 
     under subparagraph (A) prior to such information being made 
     public.
       ``(C) Website.--Such information shall be posted on the 
     Hospital Compare Internet website in an easily understandable 
     format.
       ``(7) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the following:
       ``(A) The criteria described in paragraph (2)(A).
       ``(B) The specification of hospital acquired conditions 
     under paragraph (3).
       ``(C) The specification of the applicable period under 
     paragraph (4).
       ``(D) The provision of reports to applicable hospitals 
     under paragraph (5) and the information made available to the 
     public under paragraph (6).''.
       (b) Study and Report on Expansion of Healthcare Acquired 
     Conditions Policy to Other Providers.--
       (1) Study.--The Secretary of Health and Human Services 
     shall conduct a study on expanding the healthcare acquired 
     conditions policy under subsection (d)(4)(D) of section 1886 
     of the Social Security Act (42 U.S.C. 1395ww) to payments 
     made to other facilities under the Medicare program under 
     title XVIII of the Social Security Act, including such 
     payments made to inpatient rehabilitation facilities, long-
     term care hospitals (as described in subsection(d)(1)(B)(iv) 
     of such section), hospital outpatient departments, and other 
     hospitals excluded from the inpatient prospective payment 
     system under such section, skilled nursing facilities, 
     ambulatory surgical centers, and health clinics. Such study 
     shall include an analysis of how such policies could impact 
     quality of patient care, patient safety, and spending under 
     the Medicare program.
       (2) Report.--Not later than January 1, 2012, the Secretary 
     shall submit to Congress a report containing the results of 
     the study conducted under paragraph (1), together with 
     recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.

       PART II--NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY

     SEC. 3011. NATIONAL STRATEGY.

       Title III of the Public Health Service Act (42 U.S.C. 241 
     et seq.) is amended by adding at the end the following:

[[Page 4273]]



                 ``PART S--HEALTH CARE QUALITY PROGRAMS

 ``Subpart I--National Strategy for Quality Improvement in Health Care

     ``SEC. 399HH. NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN 
                   HEALTH CARE.

       ``(a) Establishment of National Strategy and Priorities.--
       ``(1) National strategy.--The Secretary, through a 
     transparent collaborative process, shall establish a national 
     strategy to improve the delivery of health care services, 
     patient health outcomes, and population health.
       ``(2) Identification of priorities.--
       ``(A) In general.--The Secretary shall identify national 
     priorities for improvement in developing the strategy under 
     paragraph (1).
       ``(B) Requirements.--The Secretary shall ensure that 
     priorities identified under subparagraph (A) will--
       ``(i) have the greatest potential for improving the health 
     outcomes, efficiency, and patient-centeredness of health care 
     for all populations, including children and vulnerable 
     populations;
       ``(ii) identify areas in the delivery of health care 
     services that have the potential for rapid improvement in the 
     quality and efficiency of patient care;
       ``(iii) address gaps in quality, efficiency, comparative 
     effectiveness information, and health outcomes measures and 
     data aggregation techniques;
       ``(iv) improve Federal payment policy to emphasize quality 
     and efficiency;
       ``(v) enhance the use of health care data to improve 
     quality, efficiency, transparency, and outcomes;
       ``(vi) address the health care provided to patients with 
     high-cost chronic diseases;
       ``(vii) improve research and dissemination of strategies 
     and best practices to improve patient safety and reduce 
     medical errors, preventable admissions and readmissions, and 
     health care-associated infections;
       ``(viii) reduce health disparities across health disparity 
     populations (as defined in section 485E) and geographic 
     areas; and
       ``(ix) address other areas as determined appropriate by the 
     Secretary.
       ``(C) Considerations.--In identifying priorities under 
     subparagraph (A), the Secretary shall take into consideration 
     the recommendations submitted by the entity with a contract 
     under section 1890(a) of the Social Security Act and other 
     stakeholders.
       ``(D) Coordination with state agencies.--The Secretary 
     shall collaborate, coordinate, and consult with State 
     agencies responsible for administering the Medicaid program 
     under title XIX of the Social Security Act and the Children's 
     Health Insurance Program under title XXI of such Act with 
     respect to developing and disseminating strategies, goals, 
     models, and timetables that are consistent with the national 
     priorities identified under subparagraph (A).
       ``(b) Strategic Plan.--
       ``(1) In general.--The national strategy shall include a 
     comprehensive strategic plan to achieve the priorities 
     described in subsection (a).
       ``(2) Requirements.--The strategic plan shall include 
     provisions for addressing, at a minimum, the following:
       ``(A) Coordination among agencies within the Department, 
     which shall include steps to minimize duplication of efforts 
     and utilization of common quality measures, where available. 
     Such common quality measures shall be measures identified by 
     the Secretary under section 1139A or 1139B of the Social 
     Security Act or endorsed under section 1890 of such Act.
       ``(B) Agency-specific strategic plans to achieve national 
     priorities.
       ``(C) Establishment of annual benchmarks for each relevant 
     agency to achieve national priorities.
       ``(D) A process for regular reporting by the agencies to 
     the Secretary on the implementation of the strategic plan.
       ``(E) Strategies to align public and private payers with 
     regard to quality and patient safety efforts.
       ``(F) Incorporating quality improvement and measurement in 
     the strategic plan for health information technology required 
     by the American Recovery and Reinvestment Act of 2009 (Public 
     Law 111-5).
       ``(c) Periodic Update of National Strategy.--The Secretary 
     shall update the national strategy not less than annually. 
     Any such update shall include a review of short- and long-
     term goals.
       ``(d) Submission and Availability of National Strategy and 
     Updates.--
       ``(1) Deadline for initial submission of national 
     strategy.--Not later than January 1, 2011, the Secretary 
     shall submit to the relevant committees of Congress the 
     national strategy described in subsection (a).
       ``(2) Updates.--
       ``(A) In general.--The Secretary shall submit to the 
     relevant committees of Congress an annual update to the 
     strategy described in paragraph (1).
       ``(B) Information submitted.--Each update submitted under 
     subparagraph (A) shall include--
       ``(i) a review of the short- and long-term goals of the 
     national strategy and any gaps in such strategy;
       ``(ii) an analysis of the progress, or lack of progress, in 
     meeting such goals and any barriers to such progress;
       ``(iii) the information reported under section 1139A of the 
     Social Security Act, consistent with the reporting 
     requirements of such section; and
       ``(iv) in the case of an update required to be submitted on 
     or after January 1, 2014, the information reported under 
     section 1139B(b)(4) of the Social Security Act, consistent 
     with the reporting requirements of such section.
       ``(C) Satisfaction of other reporting requirements.--
     Compliance with the requirements of clauses (iii) and (iv) of 
     subparagraph (B) shall satisfy the reporting requirements 
     under sections 1139A(a)(6) and 1139B(b)(4), respectively, of 
     the Social Security Act.
       ``(e) Health Care Quality Internet Website.--Not later than 
     January 1, 2011, the Secretary shall create an Internet 
     website to make public information regarding--
       ``(1) the national priorities for health care quality 
     improvement established under subsection (a)(2);
       ``(2) the agency-specific strategic plans for health care 
     quality described in subsection (b)(2)(B); and
       ``(3) other information, as the Secretary determines to be 
     appropriate.''.

     SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH CARE QUALITY.

       (a) In General.--The President shall convene a working 
     group to be known as the Interagency Working Group on Health 
     Care Quality (referred to in this section as the ``Working 
     Group'').
       (b) Goals.--The goals of the Working Group shall be to 
     achieve the following:
       (1) Collaboration, cooperation, and consultation between 
     Federal departments and agencies with respect to developing 
     and disseminating strategies, goals, models, and timetables 
     that are consistent with the national priorities identified 
     under section 399HH(a)(2) of the Public Health Service Act 
     (as added by section 3011).
       (2) Avoidance of inefficient duplication of quality 
     improvement efforts and resources, where practicable, and a 
     streamlined process for quality reporting and compliance 
     requirements.
       (3) Assess alignment of quality efforts in the public 
     sector with private sector initiatives.
       (c) Composition.--
       (1) In general.--The Working Group shall be composed of 
     senior level representatives of--
       (A) the Department of Health and Human Services;
       (B) the Centers for Medicare & Medicaid Services;
       (C) the National Institutes of Health;
       (D) the Centers for Disease Control and Prevention;
       (E) the Food and Drug Administration;
       (F) the Health Resources and Services Administration;
       (G) the Agency for Healthcare Research and Quality;
       (H) the Office of the National Coordinator for Health 
     Information Technology;
       (I) the Substance Abuse and Mental Health Services 
     Administration;
       (J) the Administration for Children and Families;
       (K) the Department of Commerce;
       (L) the Office of Management and Budget;
       (M) the United States Coast Guard;
       (N) the Federal Bureau of Prisons;
       (O) the National Highway Traffic Safety Administration;
       (P) the Federal Trade Commission;
       (Q) the Social Security Administration;
       (R) the Department of Labor;
       (S) the United States Office of Personnel Management;
       (T) the Department of Defense;
       (U) the Department of Education;
       (V) the Department of Veterans Affairs;
       (W) the Veterans Health Administration; and
       (X) any other Federal agencies and departments with 
     activities relating to improving health care quality and 
     safety, as determined by the President.
       (2) Chair and vice-chair.--
       (A) Chair.--The Working Group shall be chaired by the 
     Secretary of Health and Human Services.
       (B) Vice chair.--Members of the Working Group, other than 
     the Secretary of Health and Human Services, shall serve as 
     Vice Chair of the Group on a rotating basis, as determined by 
     the Group.
       (d) Report to Congress.--Not later than December 31, 2010, 
     and annually thereafter, the Working Group shall submit to 
     the relevant Committees of Congress, and make public on an 
     Internet website, a report describing the progress and 
     recommendations of the Working Group in meeting the goals 
     described in subsection (b).

     SEC. 3013. QUALITY MEASURE DEVELOPMENT.

       (a) Public Health Service Act.--Title IX of the Public 
     Health Service Act (42 U.S.C. 299 et seq.) is amended--
       (1) by redesignating part D as part E;
       (2) by redesignating sections 931 through 938 as sections 
     941 through 948, respectively;
       (3) in section 948(1), as so redesignated, by striking 
     ``931'' and inserting ``941''; and
       (4) by inserting after section 926 the following:

               ``PART D--HEALTH CARE QUALITY IMPROVEMENT

                ``Subpart I--Quality Measure Development

     ``SEC. 931. QUALITY MEASURE DEVELOPMENT.

       ``(a) Quality Measure.--In this subpart, the term `quality 
     measure' means a standard for measuring the performance and 
     improvement of population health or of health plans, 
     providers of services, and other clinicians in the delivery 
     of health care services.
       ``(b) Identification of Quality Measures.--
       ``(1) Identification.--The Secretary, in consultation with 
     the Director of the Agency for Healthcare Research and 
     Quality and the Administrator of the Centers for Medicare & 
     Medicaid Services, shall identify, not less often than

[[Page 4274]]

     triennially, gaps where no quality measures exist and 
     existing quality measures that need improvement, updating, or 
     expansion, consistent with the national strategy under 
     section 399HH, to the extent available, for use in Federal 
     health programs. In identifying such gaps and existing 
     quality measures that need improvement, the Secretary shall 
     take into consideration--
       ``(A) the gaps identified by the entity with a contract 
     under section 1890(a) of the Social Security Act and other 
     stakeholders;
       ``(B) quality measures identified by the pediatric quality 
     measures program under section 1139A of the Social Security 
     Act; and
       ``(C) quality measures identified through the Medicaid 
     Quality Measurement Program under section 1139B of the Social 
     Security Act.
       ``(2) Publication.--The Secretary shall make available to 
     the public on an Internet website a report on any gaps 
     identified under paragraph (1) and the process used to make 
     such identification.
       ``(c) Grants or Contracts for Quality Measure 
     Development.--
       ``(1) In general.--The Secretary shall award grants, 
     contracts, or intergovernmental agreements to eligible 
     entities for purposes of developing, improving, updating, or 
     expanding quality measures identified under subsection (b).
       ``(2) Prioritization in the development of quality 
     measures.--In awarding grants, contracts, or agreements under 
     this subsection, the Secretary shall give priority to the 
     development of quality measures that allow the assessment 
     of--
       ``(A) health outcomes and functional status of patients;
       ``(B) the management and coordination of health care across 
     episodes of care and care transitions for patients across the 
     continuum of providers, health care settings, and health 
     plans;
       ``(C) the experience, quality, and use of information 
     provided to and used by patients, caregivers, and authorized 
     representatives to inform decisionmaking about treatment 
     options, including the use of shared decisionmaking tools and 
     preference sensitive care (as defined in section 936);
       ``(D) the meaningful use of health information technology;
       ``(E) the safety, effectiveness, patient-centeredness, 
     appropriateness, and timeliness of care;
       ``(F) the efficiency of care;
       ``(G) the equity of health services and health disparities 
     across health disparity populations (as defined in section 
     485E) and geographic areas;
       ``(H) patient experience and satisfaction;
       ``(I) the use of innovative strategies and methodologies 
     identified under section 933; and
       ``(J) other areas determined appropriate by the Secretary.
       ``(3) Eligible entities.--To be eligible for a grant or 
     contract under this subsection, an entity shall--
       ``(A) have demonstrated expertise and capacity in the 
     development and evaluation of quality measures;
       ``(B) have adopted procedures to include in the quality 
     measure development process--
       ``(i) the views of those providers or payers whose 
     performance will be assessed by the measure; and
       ``(ii) the views of other parties who also will use the 
     quality measures (such as patients, consumers, and health 
     care purchasers);
       ``(C) collaborate with the entity with a contract under 
     section 1890(a) of the Social Security Act and other 
     stakeholders, as practicable, and the Secretary so that 
     quality measures developed by the eligible entity will meet 
     the requirements to be considered for endorsement by the 
     entity with a contract under such section 1890(a);
       ``(D) have transparent policies regarding governance and 
     conflicts of interest; and
       ``(E) submit an application to the Secretary at such time 
     and in such manner, as the Secretary may require.
       ``(4) Use of funds.--An entity that receives a grant, 
     contract, or agreement under this subsection shall use such 
     award to develop quality measures that meet the following 
     requirements:
       ``(A) Such measures support measures required to be 
     reported under the Social Security Act, where applicable, and 
     in support of gaps and existing quality measures that need 
     improvement, as described in subsection (b)(1)(A).
       ``(B) Such measures support measures developed under 
     section 1139A of the Social Security Act and the Medicaid 
     Quality Measurement Program under section 1139B of such Act, 
     where applicable.
       ``(C) To the extent practicable, data on such quality 
     measures is able to be collected using health information 
     technologies.
       ``(D) Each quality measure is free of charge to users of 
     such measure.
       ``(E) Each quality measure is publicly available on an 
     Internet website.
       ``(d) Other Activities by the Secretary.--The Secretary may 
     use amounts available under this section to update and test, 
     where applicable, quality measures endorsed by the entity 
     with a contract under section 1890(a) of the Social Security 
     Act or adopted by the Secretary.
       ``(e) Coordination of Grants.--The Secretary shall ensure 
     that grants or contracts awarded under this section are 
     coordinated with grants and contracts awarded under sections 
     1139A(5) and 1139B(4)(A) of the Social Security Act.''.
       (b) Social Security Act.--Section 1890A of the Social 
     Security Act, as added by section 3014(b), is amended by 
     adding at the end the following new subsection:
       ``(e) Development of Quality Measures.--The Administrator 
     of the Center for Medicare & Medicaid Services shall through 
     contracts develop quality measures (as determined appropriate 
     by the Administrator) for use under this Act. In developing 
     such measures, the Administrator shall consult with the 
     Director of the Agency for Healthcare Research and 
     Quality.''.
       (c) Funding.--There are authorized to be appropriated to 
     the Secretary of Health and Human Services to carry out this 
     section, $75,000,000 for each of fiscal years 2010 through 
     2014. Of the amounts appropriated under the preceding 
     sentence in a fiscal year, not less than 50 percent of such 
     amounts shall be used pursuant to subsection (e) of section 
     1890A of the Social Security Act, as added by subsection (b), 
     with respect to programs under such Act. Amounts appropriated 
     under this subsection for a fiscal year shall remain 
     available until expended.

     SEC. 3014. QUALITY MEASUREMENT.

       (a) New Duties for Consensus-based Entity.--
       (1) Multi-stakeholder group input.--Section 1890(b) of the 
     Social Security Act (42 U.S.C. 1395aaa(b)), as amended by 
     section 3003, is amended by adding at the end the following 
     new paragraphs:
       ``(7) Convening multi-stakeholder groups.--
       ``(A) In general.--The entity shall convene multi-
     stakeholder groups to provide input on--
       ``(i) the selection of quality measures described in 
     subparagraph (B), from among--

       ``(I) such measures that have been endorsed by the entity; 
     and
       ``(II) such measures that have not been considered for 
     endorsement by such entity but are used or proposed to be 
     used by the Secretary for the collection or reporting of 
     quality measures; and

       ``(ii) national priorities (as identified under section 
     399HH of the Public Health Service Act) for improvement in 
     population health and in the delivery of health care services 
     for consideration under the national strategy established 
     under section 399HH of the Public Health Service Act.
       ``(B) Quality measures.--
       ``(i) In general.--Subject to clause (ii), the quality 
     measures described in this subparagraph are quality 
     measures--

       ``(I) for use pursuant to sections 1814(i)(5)(D), 
     1833(i)(7), 1833(t)(17), 1848(k)(2)(C), 1866(k)(3), 
     1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), 1886(j)(7)(D), 
     1886(m)(5)(D), 1886(o)(2), and 1895(b)(3)(B)(v);
       ``(II) for use in reporting performance information to the 
     public; and
       ``(III) for use in health care programs other than for use 
     under this Act.

       ``(ii) Exclusion.--Data sets (such as the outcome and 
     assessment information set for home health services and the 
     minimum data set for skilled nursing facility services) that 
     are used for purposes of classification systems used in 
     establishing payment rates under this title shall not be 
     quality measures described in this subparagraph.
       ``(C) Requirement for transparency in process.--
       ``(i) In general.--In convening multi-stakeholder groups 
     under subparagraph (A) with respect to the selection of 
     quality measures, the entity shall provide for an open and 
     transparent process for the activities conducted pursuant to 
     such convening.
       ``(ii) Selection of organizations participating in multi-
     stakeholder groups.--The process described in clause (i) 
     shall ensure that the selection of representatives comprising 
     such groups provides for public nominations for, and the 
     opportunity for public comment on, such selection.
       ``(D) Multi-stakeholder group defined.--In this paragraph, 
     the term `multi-stakeholder group' means, with respect to a 
     quality measure, a voluntary collaborative of organizations 
     representing a broad group of stakeholders interested in or 
     affected by the use of such quality measure.
       ``(8) Transmission of multi-stakeholder input.--Not later 
     than February 1 of each year (beginning with 2012), the 
     entity shall transmit to the Secretary the input of multi-
     stakeholder groups provided under paragraph (7).''.
       (2) Annual report.--Section 1890(b)(5)(A) of the Social 
     Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) in clause (iii), by striking the period at the end and 
     inserting a semicolon; and
       (C) by adding at the end the following new clauses:
       ``(iv) gaps in endorsed quality measures, which shall 
     include measures that are within priority areas identified by 
     the Secretary under the national strategy established under 
     section 399HH of the Public Health Service Act, and where 
     quality measures are unavailable or inadequate to identify or 
     address such gaps;
       ``(v) areas in which evidence is insufficient to support 
     endorsement of quality measures in priority areas identified 
     by the Secretary under the national strategy established 
     under section 399HH of the Public Health Service Act and 
     where targeted research may address such gaps; and
       ``(vi) the matters described in clauses (i) and (ii) of 
     paragraph (7)(A).''.
       (b) Multi-stakeholder Group Input Into Selection of Quality 
     Measures.--Title XVIII of the Social Security Act (42 U.S.C. 
     1395 et seq.)

[[Page 4275]]

     is amended by inserting after section 1890 the following:


                         ``quality measurement

       ``Sec. 1890A.  (a) Multi-stakeholder Group Input Into 
     Selection of Quality Measures.--The Secretary shall establish 
     a pre-rulemaking process under which the following steps 
     occur with respect to the selection of quality measures 
     described in section 1890(b)(7)(B):
       ``(1) Input.--Pursuant to section 1890(b)(7), the entity 
     with a contract under section 1890 shall convene multi-
     stakeholder groups to provide input to the Secretary on the 
     selection of quality measures described in subparagraph (B) 
     of such paragraph.
       ``(2) Public availability of measures considered for 
     selection.--Not later than December 1 of each year (beginning 
     with 2011), the Secretary shall make available to the public 
     a list of quality measures described in section 1890(b)(7)(B) 
     that the Secretary is considering under this title.
       ``(3) Transmission of multi-stakeholder input.--Pursuant to 
     section 1890(b)(8), not later than February 1 of each year 
     (beginning with 2012), the entity shall transmit to the 
     Secretary the input of multi-stakeholder groups described in 
     paragraph (1).
       ``(4) Consideration of multi-stakeholder input.--The 
     Secretary shall take into consideration the input from multi-
     stakeholder groups described in paragraph (1) in selecting 
     quality measures described in section 1890(b)(7)(B) that have 
     been endorsed by the entity with a contract under section 
     1890 and measures that have not been endorsed by such entity.
       ``(5) Rationale for use of quality measures.--The Secretary 
     shall publish in the Federal Register the rationale for the 
     use of any quality measure described in section 1890(b)(7)(B) 
     that has not been endorsed by the entity with a contract 
     under section 1890.
       ``(6) Assessment of impact.--Not later than March 1, 2012, 
     and at least once every three years thereafter, the Secretary 
     shall--
       ``(A) conduct an assessment of the quality impact of the 
     use of endorsed measures described in section 1890(b)(7)(B); 
     and
       ``(B) make such assessment available to the public.
       ``(b) Process for Dissemination of Measures Used by the 
     Secretary.--
       ``(1) In general.--The Secretary shall establish a process 
     for disseminating quality measures used by the Secretary. 
     Such process shall include the following:
       ``(A) The incorporation of such measures, where applicable, 
     in workforce programs, training curricula, and any other 
     means of dissemination determined appropriate by the 
     Secretary.
       ``(B) The dissemination of such quality measures through 
     the national strategy developed under section 399HH of the 
     Public Health Service Act.
       ``(2) Existing methods.--To the extent practicable, the 
     Secretary shall utilize and expand existing dissemination 
     methods in disseminating quality measures under the process 
     established under paragraph (1).
       ``(c) Review of Quality Measures Used by the Secretary.--
       ``(1) In general.--The Secretary shall--
       ``(A) periodically (but in no case less often than once 
     every 3 years) review quality measures described in section 
     1890(b)(7)(B); and
       ``(B) with respect to each such measure, determine whether 
     to--
       ``(i) maintain the use of such measure; or
       ``(ii) phase out such measure.
       ``(2) Considerations.--In conducting the review under 
     paragraph (1), the Secretary shall take steps to--
       ``(A) seek to avoid duplication of measures used; and
       ``(B) take into consideration current innovative 
     methodologies and strategies for quality improvement 
     practices in the delivery of health care services that 
     represent best practices for such quality improvement and 
     measures endorsed by the entity with a contract under section 
     1890 since the previous review by the Secretary.
       ``(d) Rule of Construction.--Nothing in this section shall 
     preclude a State from using the quality measures identified 
     under sections 1139A and 1139B.''.
       (c) Funding.--For purposes of carrying out the amendments 
     made by this section, the Secretary shall provide for the 
     transfer, from the Federal Hospital Insurance Trust Fund 
     under section 1817 of the Social Security Act (42 U.S.C. 
     1395i) and the Federal Supplementary Medical Insurance Trust 
     Fund under section 1841 of such Act (42 U.S.C. 1395t), in 
     such proportion as the Secretary determines appropriate, of 
     $20,000,000, to the Centers for Medicare & Medicaid Services 
     Program Management Account for each of fiscal years 2010 
     through 2014. Amounts transferred under the preceding 
     sentence shall remain available until expended.

     SEC. 3015. DATA COLLECTION; PUBLIC REPORTING.

       Title III of the Public Health Service Act (42 U.S.C. 241 
     et seq.), as amended by section 3011, is further amended by 
     adding at the end the following:

     ``SEC. 399II. COLLECTION AND ANALYSIS OF DATA FOR QUALITY AND 
                   RESOURCE USE MEASURES.

       ``(a) In General.--The Secretary shall collect and 
     aggregate consistent data on quality and resource use 
     measures from information systems used to support health care 
     delivery to implement the public reporting of performance 
     information, as described in section 399JJ, and may award 
     grants or contracts for this purpose. The Secretary shall 
     ensure that such collection, aggregation, and analysis 
     systems span an increasingly broad range of patient 
     populations, providers, and geographic areas over time.
       ``(b) Grants or Contracts for Data Collection.--
       ``(1) In general.--The Secretary may award grants or 
     contracts to eligible entities to support new, or improve 
     existing, efforts to collect and aggregate quality and 
     resource use measures described under subsection (c).
       ``(2) Eligible entities.--To be eligible for a grant or 
     contract under this subsection, an entity shall--
       ``(A) be--
       ``(i) a multi-stakeholder entity that coordinates the 
     development of methods and implementation plans for the 
     consistent reporting of summary quality and cost information;
       ``(ii) an entity capable of submitting such summary data 
     for a particular population and providers, such as a disease 
     registry, regional collaboration, health plan collaboration, 
     or other population-wide source; or
       ``(iii) a Federal Indian Health Service program or a health 
     program operated by an Indian tribe (as defined in section 4 
     of the Indian Health Care Improvement Act);
       ``(B) promote the use of the systems that provide data to 
     improve and coordinate patient care;
       ``(C) support the provision of timely, consistent quality 
     and resource use information to health care providers, and 
     other groups and organizations as appropriate, with an 
     opportunity for providers to correct inaccurate measures; and
       ``(D) agree to report, as determined by the Secretary, 
     measures on quality and resource use to the public in 
     accordance with the public reporting process established 
     under section 399JJ.
       ``(c) Consistent Data Aggregation.--The Secretary may award 
     grants or contracts under this section only to entities that 
     enable summary data that can be integrated and compared 
     across multiple sources. The Secretary shall provide 
     standards for the protection of the security and privacy of 
     patient data.
       ``(d) Matching Funds.--The Secretary may not award a grant 
     or contract under this section to an entity unless the entity 
     agrees that it will make available (directly or through 
     contributions from other public or private entities) non-
     Federal contributions toward the activities to be carried out 
     under the grant or contract in an amount equal to $1 for each 
     $5 of Federal funds provided under the grant or contract. 
     Such non-Federal matching funds may be provided directly or 
     through donations from public or private entities and may be 
     in cash or in-kind, fairly evaluated, including plant, 
     equipment, or services.
       ``(e) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for fiscal years 2010 through 2014.

     ``SEC. 399JJ. PUBLIC REPORTING OF PERFORMANCE INFORMATION.

       ``(a) Development of Performance Websites.--The Secretary 
     shall make available to the public, through standardized 
     Internet websites, performance information summarizing data 
     on quality measures. Such information shall be tailored to 
     respond to the differing needs of hospitals and other 
     institutional health care providers, physicians and other 
     clinicians, patients, consumers, researchers, policymakers, 
     States, and other stakeholders, as the Secretary may specify.
       ``(b) Information on Conditions.--The performance 
     information made publicly available on an Internet website, 
     as described in subsection (a), shall include information 
     regarding clinical conditions to the extent such information 
     is available, and the information shall, where appropriate, 
     be provider-specific and sufficiently disaggregated and 
     specific to meet the needs of patients with different 
     clinical conditions.
       ``(c) Consultation.--
       ``(1) In general.--In carrying out this section, the 
     Secretary shall consult with the entity with a contract under 
     section 1890(a) of the Social Security Act, and other 
     entities, as appropriate, to determine the type of 
     information that is useful to stakeholders and the format 
     that best facilitates use of the reports and of performance 
     reporting Internet websites.
       ``(2) Consultation with stakeholders.--The entity with a 
     contract under section 1890(a) of the Social Security Act 
     shall convene multi-stakeholder groups, as described in such 
     section, to review the design and format of each Internet 
     website made available under subsection (a) and shall 
     transmit to the Secretary the views of such multi-stakeholder 
     groups with respect to each such design and format.
       ``(d) Coordination.--Where appropriate, the Secretary shall 
     coordinate the manner in which data are presented through 
     Internet websites described in subsection (a) and for public 
     reporting of other quality measures by the Secretary, 
     including such quality measures under title XVIII of the 
     Social Security Act.
       ``(e) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for fiscal years 2010 through 2014.''.

      PART III--ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS

     SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID 
                   INNOVATION WITHIN CMS.

       (a) In General.--Title XI of the Social Security Act is 
     amended by inserting after section 1115 the following new 
     section:

[[Page 4276]]




             ``center for medicare and medicaid innovation

       ``Sec. 1115A.  (a) Center for Medicare and Medicaid 
     Innovation Established.--
       ``(1) In general.--There is created within the Centers for 
     Medicare & Medicaid Services a Center for Medicare and 
     Medicaid Innovation (in this section referred to as the 
     `CMI') to carry out the duties described in this section. The 
     purpose of the CMI is to test innovative payment and service 
     delivery models to reduce program expenditures under the 
     applicable titles while preserving or enhancing the quality 
     of care furnished to individuals under such titles. In 
     selecting such models, the Secretary shall give preference to 
     models that also improve the coordination, quality, and 
     efficiency of health care services furnished to applicable 
     individuals defined in paragraph (4)(A).
       ``(2) Deadline.--The Secretary shall ensure that the CMI is 
     carrying out the duties described in this section by not 
     later than January 1, 2011.
       ``(3) Consultation.--In carrying out the duties under this 
     section, the CMI shall consult representatives of relevant 
     Federal agencies, and clinical and analytical experts with 
     expertise in medicine and health care management. The CMI 
     shall use open door forums or other mechanisms to seek input 
     from interested parties.
       ``(4) Definitions.--In this section:
       ``(A) Applicable individual.--The term `applicable 
     individual' means--
       ``(i) an individual who is entitled to, or enrolled for, 
     benefits under part A of title XVIII or enrolled for benefits 
     under part B of such title;
       ``(ii) an individual who is eligible for medical assistance 
     under title XIX, under a State plan or waiver; or
       ``(iii) an individual who meets the criteria of both 
     clauses (i) and (ii).
       ``(B) Applicable title.--The term `applicable title' means 
     title XVIII, title XIX, or both.
       ``(b) Testing of Models (Phase I).--
       ``(1) In general.--The CMI shall test payment and service 
     delivery models in accordance with selection criteria under 
     paragraph (2) to determine the effect of applying such models 
     under the applicable title (as defined in subsection 
     (a)(4)(B)) on program expenditures under such titles and the 
     quality of care received by individuals receiving benefits 
     under such title.
       ``(2) Selection of models to be tested.--
       ``(A) In general.--The Secretary shall select models to be 
     tested from models where the Secretary determines that there 
     is evidence that the model addresses a defined population for 
     which there are deficits in care leading to poor clinical 
     outcomes or potentially avoidable expenditures. The models 
     selected under the preceding sentence may include the models 
     described in subparagraph (B).
       ``(B) Opportunities.--The models described in this 
     subparagraph are the following models:
       ``(i) Promoting broad payment and practice reform in 
     primary care, including patient-centered medical home models 
     for high-need applicable individuals, medical homes that 
     address women's unique health care needs, and models that 
     transition primary care practices away from fee-for-service 
     based reimbursement and toward comprehensive payment or 
     salary-based payment.
       ``(ii) Contracting directly with groups of providers of 
     services and suppliers to promote innovative care delivery 
     models, such as through risk-based comprehensive payment or 
     salary-based payment.
       ``(iii) Utilizing geriatric assessments and comprehensive 
     care plans to coordinate the care (including through 
     interdisciplinary teams) of applicable individuals with 
     multiple chronic conditions and at least one of the 
     following:

       ``(I) An inability to perform 2 or more activities of daily 
     living.
       ``(II) Cognitive impairment, including dementia.

       ``(iv) Promote care coordination between providers of 
     services and suppliers that transition health care providers 
     away from fee-for-service based reimbursement and toward 
     salary-based payment.
       ``(v) Supporting care coordination for chronically-ill 
     applicable individuals at high risk of hospitalization 
     through a health information technology-enabled provider 
     network that includes care coordinators, a chronic disease 
     registry, and home tele-health technology.
       ``(vi) Varying payment to physicians who order advanced 
     diagnostic imaging services (as defined in section 
     1834(e)(1)(B)) according to the physician's adherence to 
     appropriateness criteria for the ordering of such services, 
     as determined in consultation with physician specialty groups 
     and other relevant stakeholders.
       ``(vii) Utilizing medication therapy management services, 
     such as those described in section 935 of the Public Health 
     Service Act.
       ``(viii) Establishing community-based health teams to 
     support small-practice medical homes by assisting the primary 
     care practitioner in chronic care management, including 
     patient self-management, activities.
       ``(ix) Assisting applicable individuals in making informed 
     health care choices by paying providers of services and 
     suppliers for using patient decision-support tools, including 
     tools that meet the standards developed and identified under 
     section 936(c)(2)(A) of the Public Health Service Act, that 
     improve applicable individual and caregiver understanding of 
     medical treatment options.
       ``(x) Allowing States to test and evaluate fully 
     integrating care for dual eligible individuals in the State, 
     including the management and oversight of all funds under the 
     applicable titles with respect to such individuals.
       ``(xi) Allowing States to test and evaluate systems of all-
     payer payment reform for the medical care of residents of the 
     State, including dual eligible individuals.
       ``(xii) Aligning nationally recognized, evidence-based 
     guidelines of cancer care with payment incentives under title 
     XVIII in the areas of treatment planning and follow-up care 
     planning for applicable individuals described in clause (i) 
     or (iii) of subsection (a)(4)(A) with cancer, including the 
     identification of gaps in applicable quality measures.
       ``(xiii) Improving post-acute care through continuing care 
     hospitals that offer inpatient rehabilitation, long-term care 
     hospitals, and home health or skilled nursing care during an 
     inpatient stay and the 30 days immediately following 
     discharge.
       ``(xiv) Funding home health providers who offer chronic 
     care management services to applicable individuals in 
     cooperation with interdisciplinary teams.
       ``(xv) Promoting improved quality and reduced cost by 
     developing a collaborative of high-quality, low-cost health 
     care institutions that is responsible for--

       ``(I) developing, documenting, and disseminating best 
     practices and proven care methods;
       ``(II) implementing such best practices and proven care 
     methods within such institutions to demonstrate further 
     improvements in quality and efficiency; and
       ``(III) providing assistance to other health care 
     institutions on how best to employ such best practices and 
     proven care methods to improve health care quality and lower 
     costs.

       ``(xvi) Facilitate inpatient care, including intensive 
     care, of hospitalized applicable individuals at their local 
     hospital through the use of electronic monitoring by 
     specialists, including intensivists and critical care 
     specialists, based at integrated health systems.
       ``(xvii) Promoting greater efficiencies and timely access 
     to outpatient services (such as outpatient physical therapy 
     services) through models that do not require a physician or 
     other health professional to refer the service or be involved 
     in establishing the plan of care for the service, when such 
     service is furnished by a health professional who has the 
     authority to furnish the service under existing State law.
       ``(xviii) Establishing comprehensive payments to Healthcare 
     Innovation Zones, consisting of groups of providers that 
     include a teaching hospital, physicians, and other clinical 
     entities, that, through their structure, operations, and 
     joint-activity deliver a full spectrum of integrated and 
     comprehensive health care services to applicable individuals 
     while also incorporating innovative methods for the clinical 
     training of future health care professionals.
       ``(C) Additional factors for consideration.--In selecting 
     models for testing under subparagraph (A), the CMI may 
     consider the following additional factors:
       ``(i) Whether the model includes a regular process for 
     monitoring and updating patient care plans in a manner that 
     is consistent with the needs and preferences of applicable 
     individuals.
       ``(ii) Whether the model places the applicable individual, 
     including family members and other informal caregivers of the 
     applicable individual, at the center of the care team of the 
     applicable individual.
       ``(iii) Whether the model provides for in-person contact 
     with applicable individuals.
       ``(iv) Whether the model utilizes technology, such as 
     electronic health records and patient-based remote monitoring 
     systems, to coordinate care over time and across settings.
       ``(v) Whether the model provides for the maintenance of a 
     close relationship between care coordinators, primary care 
     practitioners, specialist physicians, community-based 
     organizations, and other providers of services and suppliers.
       ``(vi) Whether the model relies on a team-based approach to 
     interventions, such as comprehensive care assessments, care 
     planning, and self-management coaching.
       ``(vii) Whether, under the model, providers of services and 
     suppliers are able to share information with patients, 
     caregivers, and other providers of services and suppliers on 
     a real time basis.
       ``(3) Budget neutrality.--
       ``(A) Initial period.--The Secretary shall not require, as 
     a condition for testing a model under paragraph (1), that the 
     design of such model ensure that such model is budget neutral 
     initially with respect to expenditures under the applicable 
     title.
       ``(B) Termination or modification.--The Secretary shall 
     terminate or modify the design and implementation of a model 
     unless the Secretary determines (and the Chief Actuary of the 
     Centers for Medicare & Medicaid Services, with respect to 
     program spending under the applicable title, certifies), 
     after testing has begun, that the model is expected to--
       ``(i) improve the quality of care (as determined by the 
     Administrator of the Centers for Medicare & Medicaid 
     Services) without increasing spending under the applicable 
     title;
       ``(ii) reduce spending under the applicable title without 
     reducing the quality of care; or
       ``(iii) improve the quality of care and reduce spending.

     Such termination may occur at any time after such testing has 
     begun and before completion of the testing.
       ``(4) Evaluation.--
       ``(A) In general.--The Secretary shall conduct an 
     evaluation of each model tested under

[[Page 4277]]

     this subsection. Such evaluation shall include an analysis 
     of--
       ``(i) the quality of care furnished under the model, 
     including the measurement of patient-level outcomes and 
     patient-centeredness criteria determined appropriate by the 
     Secretary; and
       ``(ii) the changes in spending under the applicable titles 
     by reason of the model.
       ``(B) Information.--The Secretary shall make the results of 
     each evaluation under this paragraph available to the public 
     in a timely fashion and may establish requirements for States 
     and other entities participating in the testing of models 
     under this section to collect and report information that the 
     Secretary determines is necessary to monitor and evaluate 
     such models.
       ``(c) Expansion of Models (Phase II).--Taking into account 
     the evaluation under subsection (b)(4), the Secretary may, 
     through rulemaking, expand (including implementation on a 
     nationwide basis) the duration and the scope of a model that 
     is being tested under subsection (b) or a demonstration 
     project under section 1866C, to the extent determined 
     appropriate by the Secretary, if--
       ``(1) the Secretary determines that such expansion is 
     expected to--
       ``(A) reduce spending under applicable title without 
     reducing the quality of care; or
       ``(B) improve the quality of care and reduce spending; and
       ``(2) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     program spending under applicable titles.
       ``(d) Implementation.--
       ``(1) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII and of sections 
     1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) as may be 
     necessary solely for purposes of carrying out this section 
     with respect to testing models described in subsection (b).
       ``(2) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(A) the selection of models for testing or expansion 
     under this section;
       ``(B) the selection of organizations, sites, or 
     participants to test those models selected;
       ``(C) the elements, parameters, scope, and duration of such 
     models for testing or dissemination;
       ``(D) determinations regarding budget neutrality under 
     subsection (b)(3);
       ``(E) the termination or modification of the design and 
     implementation of a model under subsection (b)(3)(B); and
       ``(F) determinations about expansion of the duration and 
     scope of a model under subsection (c), including the 
     determination that a model is not expected to meet criteria 
     described in paragraph (1) or (2) of such subsection.
       ``(3) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to the testing and evaluation of 
     models or expansion of such models under this section.
       ``(e) Application to CHIP.--The Center may carry out 
     activities under this section with respect to title XXI in 
     the same manner as provided under this section with respect 
     to the program under the applicable titles.
       ``(f) Funding.--
       ``(1) In general.--There are appropriated, from amounts in 
     the Treasury not otherwise appropriated--
       ``(A) $5,000,000 for the design, implementation, and 
     evaluation of models under subsection (b) for fiscal year 
     2010;
       ``(B) $10,000,000,000 for the activities initiated under 
     this section for the period of fiscal years 2011 through 
     2019; and
       ``(C) the amount described in subparagraph (B) for the 
     activities initiated under this section for each subsequent 
     10-year fiscal period (beginning with the 10-year fiscal 
     period beginning with fiscal year 2020).

     Amounts appropriated under the preceding sentence shall 
     remain available until expended.
       ``(2) Use of certain funds.--Out of amounts appropriated 
     under subparagraphs (B) and (C) of paragraph (1), not less 
     than $25,000,000 shall be made available each such fiscal 
     year to design, implement, and evaluate models under 
     subsection (b).
       ``(g) Report to Congress.--Beginning in 2012, and not less 
     than once every other year thereafter, the Secretary shall 
     submit to Congress a report on activities under this section. 
     Each such report shall describe the models tested under 
     subsection (b), including the number of individuals described 
     in subsection (a)(4)(A)(i) and of individuals described in 
     subsection (a)(4)(A)(ii) participating in such models and 
     payments made under applicable titles for services on behalf 
     of such individuals, any models chosen for expansion under 
     subsection (c), and the results from evaluations under 
     subsection (b)(4). In addition, each such report shall 
     provide such recommendations as the Secretary determines are 
     appropriate for legislative action to facilitate the 
     development and expansion of successful payment models.''.
       (b) Medicaid Conforming Amendment.--Section 1902(a) of the 
     Social Security Act (42 U.S.C. 1396a(a)), as amended by 
     section 8002(b), is amended--
       (1) in paragraph (81), by striking ``and'' at the end;
       (2) in paragraph (82), by striking the period at the end 
     and inserting ``; and''; and
       (3) by inserting after paragraph (82) the following new 
     paragraph:
       ``(83) provide for implementation of the payment models 
     specified by the Secretary under section 1115A(c) for 
     implementation on a nationwide basis unless the State 
     demonstrates to the satisfaction of the Secretary that 
     implementation would not be administratively feasible or 
     appropriate to the health care delivery system of the 
     State.''.
       (c) Revisions to Health Care Quality Demonstration 
     Program.--Subsections (b) and (f) of section 1866C of the 
     Social Security Act (42 U.S.C. 1395cc-3) are amended by 
     striking ``5-year'' each place it appears.

     SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM.

       Title XVIII of the Social Security Act (42 U.S.C. 1395 et 
     seq.) is amended by adding at the end the following new 
     section:


                        ``shared savings program

       ``Sec. 1899.  (a) Establishment.--
       ``(1) In general.--Not later than January 1, 2012, the 
     Secretary shall establish a shared savings program (in this 
     section referred to as the `program') that promotes 
     accountability for a patient population and coordinates items 
     and services under parts A and B, and encourages investment 
     in infrastructure and redesigned care processes for high 
     quality and efficient service delivery. Under such program--
       ``(A) groups of providers of services and suppliers meeting 
     criteria specified by the Secretary may work together to 
     manage and coordinate care for Medicare fee-for-service 
     beneficiaries through an accountable care organization 
     (referred to in this section as an `ACO'); and
       ``(B) ACOs that meet quality performance standards 
     established by the Secretary are eligible to receive payments 
     for shared savings under subsection (d)(2).
       ``(b) Eligible ACOs.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, as determined appropriate by the Secretary, 
     the following groups of providers of services and suppliers 
     which have established a mechanism for shared governance are 
     eligible to participate as ACOs under the program under this 
     section:
       ``(A) ACO professionals in group practice arrangements.
       ``(B) Networks of individual practices of ACO 
     professionals.
       ``(C) Partnerships or joint venture arrangements between 
     hospitals and ACO professionals.
       ``(D) Hospitals employing ACO professionals.
       ``(E) Such other groups of providers of services and 
     suppliers as the Secretary determines appropriate.
       ``(2) Requirements.--An ACO shall meet the following 
     requirements:
       ``(A) The ACO shall be willing to become accountable for 
     the quality, cost, and overall care of the Medicare fee-for-
     service beneficiaries assigned to it.
       ``(B) The ACO shall enter into an agreement with the 
     Secretary to participate in the program for not less than a 
     3-year period (referred to in this section as the `agreement 
     period').
       ``(C) The ACO shall have a formal legal structure that 
     would allow the organization to receive and distribute 
     payments for shared savings under subsection (d)(2) to 
     participating providers of services and suppliers.
       ``(D) The ACO shall include primary care ACO professionals 
     that are sufficient for the number of Medicare fee-for-
     service beneficiaries assigned to the ACO under subsection 
     (c). At a minimum, the ACO shall have at least 5,000 such 
     beneficiaries assigned to it under subsection (c) in order to 
     be eligible to participate in the ACO program.
       ``(E) The ACO shall provide the Secretary with such 
     information regarding ACO professionals participating in the 
     ACO as the Secretary determines necessary to support the 
     assignment of Medicare fee-for-service beneficiaries to an 
     ACO, the implementation of quality and other reporting 
     requirements under paragraph (3), and the determination of 
     payments for shared savings under subsection (d)(2).
       ``(F) The ACO shall have in place a leadership and 
     management structure that includes clinical and 
     administrative systems.
       ``(G) The ACO shall define processes to promote evidence-
     based medicine and patient engagement, report on quality and 
     cost measures, and coordinate care, such as through the use 
     of telehealth, remote patient monitoring, and other such 
     enabling technologies.
       ``(H) The ACO shall demonstrate to the Secretary that it 
     meets patient-centeredness criteria specified by the 
     Secretary, such as the use of patient and caregiver 
     assessments or the use of individualized care plans.
       ``(3) Quality and other reporting requirements.--
       ``(A) In general.--The Secretary shall determine 
     appropriate measures to assess the quality of care furnished 
     by the ACO, such as measures of--
       ``(i) clinical processes and outcomes;
       ``(ii) patient and, where practicable, caregiver experience 
     of care; and
       ``(iii) utilization (such as rates of hospital admissions 
     for ambulatory care sensitive conditions).
       ``(B) Reporting requirements.--An ACO shall submit data in 
     a form and manner specified by the Secretary on measures the 
     Secretary determines necessary for the ACO to report in order 
     to evaluate the quality of care furnished by the ACO. Such 
     data may include care transitions across health care 
     settings, including hospital discharge planning and post-
     hospital discharge follow-up by ACO professionals, as the 
     Secretary determines appropriate.
       ``(C) Quality performance standards.--The Secretary shall 
     establish quality performance standards to assess the quality 
     of care furnished

[[Page 4278]]

     by ACOs. The Secretary shall seek to improve the quality of 
     care furnished by ACOs over time by specifying higher 
     standards, new measures, or both for purposes of assessing 
     such quality of care.
       ``(D) Other reporting requirements.--The Secretary may, as 
     the Secretary determines appropriate, incorporate reporting 
     requirements and incentive payments related to the physician 
     quality reporting initiative (PQRI) under section 1848, 
     including such requirements and such payments related to 
     electronic prescribing, electronic health records, and other 
     similar initiatives under section 1848, and may use 
     alternative criteria than would otherwise apply under such 
     section for determining whether to make such payments. The 
     incentive payments described in the preceding sentence shall 
     not be taken into consideration when calculating any payments 
     otherwise made under subsection (d).
       ``(4) No duplication in participation in shared savings 
     programs.--A provider of services or supplier that 
     participates in any of the following shall not be eligible to 
     participate in an ACO under this section:
       ``(A) A model tested or expanded under section 1115A that 
     involves shared savings under this title, or any other 
     program or demonstration project that involves such shared 
     savings.
       ``(B) The independence at home medical practice pilot 
     program under section 1866E.
       ``(c) Assignment of Medicare Fee-for-service Beneficiaries 
     to ACOs.--The Secretary shall determine an appropriate method 
     to assign Medicare fee-for-service beneficiaries to an ACO 
     based on their utilization of primary care services provided 
     under this title by an ACO professional described in 
     subsection (h)(1)(A).
       ``(d) Payments and Treatment of Savings.--
       ``(1) Payments.--
       ``(A) In general.--Under the program, subject to paragraph 
     (3), payments shall continue to be made to providers of 
     services and suppliers participating in an ACO under the 
     original Medicare fee-for-service program under parts A and B 
     in the same manner as they would otherwise be made except 
     that a participating ACO is eligible to receive payment for 
     shared savings under paragraph (2) if--
       ``(i) the ACO meets quality performance standards 
     established by the Secretary under subsection (b)(3); and
       ``(ii) the ACO meets the requirement under subparagraph 
     (B)(i).
       ``(B) Savings requirement and benchmark.--
       ``(i) Determining savings.--In each year of the agreement 
     period, an ACO shall be eligible to receive payment for 
     shared savings under paragraph (2) only if the estimated 
     average per capita Medicare expenditures under the ACO for 
     Medicare fee-for-service beneficiaries for parts A and B 
     services, adjusted for beneficiary characteristics, is at 
     least the percent specified by the Secretary below the 
     applicable benchmark under clause (ii). The Secretary shall 
     determine the appropriate percent described in the preceding 
     sentence to account for normal variation in expenditures 
     under this title, based upon the number of Medicare fee-for-
     service beneficiaries assigned to an ACO.
       ``(ii) Establish and update benchmark.--The Secretary shall 
     estimate a benchmark for each agreement period for each ACO 
     using the most recent available 3 years of per-beneficiary 
     expenditures for parts A and B services for Medicare fee-for-
     service beneficiaries assigned to the ACO. Such benchmark 
     shall be adjusted for beneficiary characteristics and such 
     other factors as the Secretary determines appropriate and 
     updated by the projected absolute amount of growth in 
     national per capita expenditures for parts A and B services 
     under the original Medicare fee-for-service program, as 
     estimated by the Secretary. Such benchmark shall be reset at 
     the start of each agreement period.
       ``(2) Payments for shared savings.--Subject to performance 
     with respect to the quality performance standards established 
     by the Secretary under subsection (b)(3), if an ACO meets the 
     requirements under paragraph (1), a percent (as determined 
     appropriate by the Secretary) of the difference between such 
     estimated average per capita Medicare expenditures in a year, 
     adjusted for beneficiary characteristics, under the ACO and 
     such benchmark for the ACO may be paid to the ACO as shared 
     savings and the remainder of such difference shall be 
     retained by the program under this title. The Secretary shall 
     establish limits on the total amount of shared savings that 
     may be paid to an ACO under this paragraph.
       ``(3) Monitoring avoidance of at-risk patients.--If the 
     Secretary determines that an ACO has taken steps to avoid 
     patients at risk in order to reduce the likelihood of 
     increasing costs to the ACO the Secretary may impose an 
     appropriate sanction on the ACO, including termination from 
     the program.
       ``(4) Termination.--The Secretary may terminate an 
     agreement with an ACO if it does not meet the quality 
     performance standards established by the Secretary under 
     subsection (b)(3).
       ``(e) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to the program.
       ``(f) Waiver Authority.--The Secretary may waive such 
     requirements of sections 1128A and 1128B and title XVIII of 
     this Act as may be necessary to carry out the provisions of 
     this section.
       ``(g) Limitations on Review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(1) the specification of criteria under subsection 
     (a)(1)(B);
       ``(2) the assessment of the quality of care furnished by an 
     ACO and the establishment of performance standards under 
     subsection (b)(3);
       ``(3) the assignment of Medicare fee-for-service 
     beneficiaries to an ACO under subsection (c);
       ``(4) the determination of whether an ACO is eligible for 
     shared savings under subsection (d)(2) and the amount of such 
     shared savings, including the determination of the estimated 
     average per capita Medicare expenditures under the ACO for 
     Medicare fee-for-service beneficiaries assigned to the ACO 
     and the average benchmark for the ACO under subsection 
     (d)(1)(B);
       ``(5) the percent of shared savings specified by the 
     Secretary under subsection (d)(2) and any limit on the total 
     amount of shared savings established by the Secretary under 
     such subsection; and
       ``(6) the termination of an ACO under subsection (d)(4).
       ``(h) Definitions.--In this section:
       ``(1) ACO professional.--The term `ACO professional' 
     means--
       ``(A) a physician (as defined in section 1861(r)(1)); and
       ``(B) a practitioner described in section 
     1842(b)(18)(C)(i).
       ``(2) Hospital.--The term `hospital' means a subsection (d) 
     hospital (as defined in section 1886(d)(1)(B)).
       ``(3) Medicare fee-for-service beneficiary.--The term 
     `Medicare fee-for-service beneficiary' means an individual 
     who is enrolled in the original Medicare fee-for-service 
     program under parts A and B and is not enrolled in an MA plan 
     under part C, an eligible organization under section 1876, or 
     a PACE program under section 1894.''.

     SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING.

       Title XVIII of the Social Security Act, as amended by 
     section 3021, is amended by inserting after section 1886C the 
     following new section:


              ``national pilot program on payment bundling

       ``Sec. 1866D.  (a) Implementation.--
       ``(1) In general.--The Secretary shall establish a pilot 
     program for integrated care during an episode of care 
     provided to an applicable beneficiary around a 
     hospitalization in order to improve the coordination, 
     quality, and efficiency of health care services under this 
     title.
       ``(2) Definitions.--In this section:
       ``(A) Applicable beneficiary.--The term `applicable 
     beneficiary' means an individual who--
       ``(i) is entitled to, or enrolled for, benefits under part 
     A and enrolled for benefits under part B of such title, but 
     not enrolled under part C or a PACE program under section 
     1894; and
       ``(ii) is admitted to a hospital for an applicable 
     condition.
       ``(B) Applicable condition.--The term `applicable 
     condition' means 1 or more of 8 conditions selected by the 
     Secretary. In selecting conditions under the preceding 
     sentence, the Secretary shall take into consideration the 
     following factors:
       ``(i) Whether the conditions selected include a mix of 
     chronic and acute conditions.
       ``(ii) Whether the conditions selected include a mix of 
     surgical and medical conditions.
       ``(iii) Whether a condition is one for which there is 
     evidence of an opportunity for providers of services and 
     suppliers to improve the quality of care furnished while 
     reducing total expenditures under this title.
       ``(iv) Whether a condition has significant variation in--

       ``(I) the number of readmissions; and
       ``(II) the amount of expenditures for post-acute care 
     spending under this title.

       ``(v) Whether a condition is high-volume and has high post-
     acute care expenditures under this title.
       ``(vi) Which conditions the Secretary determines are most 
     amenable to bundling across the spectrum of care given 
     practice patterns under this title.
       ``(C) Applicable services.--The term `applicable services' 
     means the following:
       ``(i) Acute care inpatient services.
       ``(ii) Physicians' services delivered in and outside of an 
     acute care hospital setting.
       ``(iii) Outpatient hospital services, including emergency 
     department services.
       ``(iv) Post-acute care services, including home health 
     services, skilled nursing services, inpatient rehabilitation 
     services, and inpatient hospital services furnished by a 
     long-term care hospital.
       ``(v) Other services the Secretary determines appropriate.
       ``(D) Episode of care.--
       ``(i) In general.--Subject to clause (ii), the term 
     `episode of care' means, with respect to an applicable 
     condition and an applicable beneficiary, the period that 
     includes--

       ``(I) the 3 days prior to the admission of the applicable 
     beneficiary to a hospital for the applicable condition;
       ``(II) the length of stay of the applicable beneficiary in 
     such hospital; and
       ``(III) the 30 days following the discharge of the 
     applicable beneficiary from such hospital.

       ``(ii) Establishment of period by the secretary.--The 
     Secretary, as appropriate, may establish a period (other than 
     the period described in clause (i)) for an episode of care 
     under the pilot program.
       ``(E) Physicians' services.--The term `physicians' 
     services' has the meaning given such term in section 1861(q).
       ``(F) Pilot program.--The term `pilot program' means the 
     pilot program under this section.

[[Page 4279]]

       ``(G) Provider of services.--The term `provider of 
     services' has the meaning given such term in section 1861(u).
       ``(H) Readmission.--The term `readmission' has the meaning 
     given such term in section 1886(q)(5)(E).
       ``(I) Supplier.--The term `supplier' has the meaning given 
     such term in section 1861(d).
       ``(3) Deadline for implementation.--The Secretary shall 
     establish the pilot program not later than January 1, 2013.
       ``(b) Developmental Phase.--
       ``(1) Determination of patient assessment instrument.--The 
     Secretary shall determine which patient assessment instrument 
     (such as the Continuity Assessment Record and Evaluation 
     (CARE) tool) shall be used under the pilot program to 
     evaluate the applicable condition of an applicable 
     beneficiary for purposes of determining the most clinically 
     appropriate site for the provision of post-acute care to the 
     applicable beneficiary.
       ``(2) Development of quality measures for an episode of 
     care and for post-acute care.--
       ``(A) In general.--The Secretary, in consultation with the 
     Agency for Healthcare Research and Quality and the entity 
     with a contract under section 1890(a) of the Social Security 
     Act, shall develop quality measures for use in the pilot 
     program--
       ``(i) for episodes of care; and
       ``(ii) for post-acute care.
       ``(B) Site-neutral post-acute care quality measures.--Any 
     quality measures developed under subparagraph (A)(ii) shall 
     be site-neutral.
       ``(C) Coordination with quality measure development and 
     endorsement procedures.--The Secretary shall ensure that the 
     development of quality measures under subparagraph (A) is 
     done in a manner that is consistent with the measures 
     developed and endorsed under section 1890 and 1890A that are 
     applicable to all post-acute care settings.
       ``(c) Details.--
       ``(1) Duration.--
       ``(A) In general.--Subject to subparagraph (B), the pilot 
     program shall be conducted for a period of 5 years.
       ``(B) Extension.--The Secretary may extend the duration of 
     the pilot program for providers of services and suppliers 
     participating in the pilot program as of the day before the 
     end of the 5-year period described in subparagraph (A), for a 
     period determined appropriate by the Secretary, if the 
     Secretary determines that such extension will result in 
     improving or not reducing the quality of patient care and 
     reducing spending under this title.
       ``(2) Participating providers of services and suppliers.--
       ``(A) In general.--An entity comprised of providers of 
     services and suppliers, including a hospital, a physician 
     group, a skilled nursing facility, and a home health agency, 
     who are otherwise participating under this title, may submit 
     an application to the Secretary to provide applicable 
     services to applicable individuals under this section.
       ``(B) Requirements.--The Secretary shall develop 
     requirements for entities to participate in the pilot program 
     under this section. Such requirements shall ensure that 
     applicable beneficiaries have an adequate choice of providers 
     of services and suppliers under the pilot program.
       ``(3) Payment methodology.--
       ``(A) In general.--
       ``(i) Establishment of payment methods.--The Secretary 
     shall develop payment methods for the pilot program for 
     entities participating in the pilot program. Such payment 
     methods may include bundled payments and bids from entities 
     for episodes of care. The Secretary shall make payments to 
     the entity for services covered under this section.
       ``(ii) No additional program expenditures.--Payments under 
     this section for applicable items and services under this 
     title (including payment for services described in 
     subparagraph (B)) for applicable beneficiaries for a year 
     shall be established in a manner that does not result in 
     spending more for such entity for such beneficiaries than 
     would otherwise be expended for such entity for such 
     beneficiaries for such year if the pilot program were not 
     implemented, as estimated by the Secretary.
       ``(B) Inclusion of certain services.--A payment methodology 
     tested under the pilot program shall include payment for the 
     furnishing of applicable services and other appropriate 
     services, such as care coordination, medication 
     reconciliation, discharge planning, transitional care 
     services, and other patient-centered activities as determined 
     appropriate by the Secretary.
       ``(C) Bundled payments.--
       ``(i) In general.--A bundled payment under the pilot 
     program shall--

       ``(I) be comprehensive, covering the costs of applicable 
     services and other appropriate services furnished to an 
     individual during an episode of care (as determined by the 
     Secretary); and
       ``(II) be made to the entity which is participating in the 
     pilot program.

       ``(ii) Requirement for provision of applicable services and 
     other appropriate services.--Applicable services and other 
     appropriate services for which payment is made under this 
     subparagraph shall be furnished or directed by the entity 
     which is participating in the pilot program.
       ``(D) Payment for post-acute care services after the 
     episode of care.--The Secretary shall establish procedures, 
     in the case where an applicable beneficiary requires 
     continued post-acute care services after the last day of the 
     episode of care, under which payment for such services shall 
     be made.
       ``(4) Quality measures.--
       ``(A) In general.--The Secretary shall establish quality 
     measures (including quality measures of process, outcome, and 
     structure) related to care provided by entities participating 
     in the pilot program. Quality measures established under the 
     preceding sentence shall include measures of the following:
       ``(i) Functional status improvement.
       ``(ii) Reducing rates of avoidable hospital readmissions.
       ``(iii) Rates of discharge to the community.
       ``(iv) Rates of admission to an emergency room after a 
     hospitalization.
       ``(v) Incidence of health care acquired infections.
       ``(vi) Efficiency measures.
       ``(vii) Measures of patient-centeredness of care.
       ``(viii) Measures of patient perception of care.
       ``(ix) Other measures, including measures of patient 
     outcomes, determined appropriate by the Secretary.
       ``(B) Reporting on quality measures.--
       ``(i) In general.--A entity shall submit data to the 
     Secretary on quality measures established under subparagraph 
     (A) during each year of the pilot program (in a form and 
     manner, subject to clause (iii), specified by the Secretary).
       ``(ii) Submission of data through electronic health 
     record.--To the extent practicable, the Secretary shall 
     specify that data on measures be submitted under clause (i) 
     through the use of an qualified electronic health record (as 
     defined in section 3000(13) of the Public Health Service Act 
     (42 U.S.C. 300jj-11(13)) in a manner specified by the 
     Secretary.
       ``(d) Waiver.--The Secretary may waive such provisions of 
     this title and title XI as may be necessary to carry out the 
     pilot program.
       ``(e) Independent Evaluation and Reports on Pilot 
     Program.--
       ``(1) Independent evaluation.--The Secretary shall conduct 
     an independent evaluation of the pilot program, including the 
     extent to which the pilot program has--
       ``(A) improved quality measures established under 
     subsection (c)(4)(A);
       ``(B) improved health outcomes;
       ``(C) improved applicable beneficiary access to care; and
       ``(D) reduced spending under this title.
       ``(2) Reports.--
       ``(A) Interim report.--Not later than 2 years after the 
     implementation of the pilot program, the Secretary shall 
     submit to Congress a report on the initial results of the 
     independent evaluation conducted under paragraph (1).
       ``(B) Final report.--Not later than 3 years after the 
     implementation of the pilot program, the Secretary shall 
     submit to Congress a report on the final results of the 
     independent evaluation conducted under paragraph (1).
       ``(f) Consultation.--The Secretary shall consult with 
     representatives of small rural hospitals, including critical 
     access hospitals (as defined in section 1861(mm)(1)), 
     regarding their participation in the pilot program. Such 
     consultation shall include consideration of innovative 
     methods of implementing bundled payments in hospitals 
     described in the preceding sentence, taking into 
     consideration any difficulties in doing so as a result of the 
     low volume of services provided by such hospitals.
       ``(g) Implementation Plan.--
       ``(1) In general.--Not later than January 1, 2016, the 
     Secretary shall submit a plan for the implementation of an 
     expansion of the pilot program if the Secretary determines 
     that such expansion will result in improving or not reducing 
     the quality of patient care and reducing spending under this 
     title.
       ``(h) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to the selection, testing, and 
     evaluation of models or the expansion of such models under 
     this section.''.

     SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.

       Title XVIII of the Social Security Act is amended by 
     inserting after section 1866D, as inserted by section 3023, 
     the following new section:


     ``independence at home medical practice demonstration program

       ``Sec. 1866D.  (a) Establishment.--
       ``(1) In general.--The Secretary shall conduct a 
     demonstration program (in this section referred to as the 
     `demonstration program') to test a payment incentive and 
     service delivery model that utilizes physician and nurse 
     practitioner directed home-based primary care teams designed 
     to reduce expenditures and improve health outcomes in the 
     provision of items and services under this title to 
     applicable beneficiaries (as defined in subsection (d)).
       ``(2) Requirement.--The demonstration program shall test 
     whether a model described in paragraph (1), which is 
     accountable for providing comprehensive, coordinated, 
     continuous, and accessible care to high-need populations at 
     home and coordinating health care across all treatment 
     settings, results in--
       ``(A) reducing preventable hospitalizations;
       ``(B) preventing hospital readmissions;
       ``(C) reducing emergency room visits;
       ``(D) improving health outcomes commensurate with the 
     beneficiaries' stage of chronic illness;
       ``(E) improving the efficiency of care, such as by reducing 
     duplicative diagnostic and laboratory tests;
       ``(F) reducing the cost of health care services covered 
     under this title; and
       ``(G) achieving beneficiary and family caregiver 
     satisfaction.
       ``(b) Independence at Home Medical Practice.--

[[Page 4280]]

       ``(1) Independence at home medical practice defined.--In 
     this section:
       ``(A) In general.--The term `independence at home medical 
     practice' means a legal entity that--
       ``(i) is comprised of an individual physician or nurse 
     practitioner or group of physicians and nurse practitioners 
     that provides care as part of a team that includes 
     physicians, nurses, physician assistants, pharmacists, and 
     other health and social services staff as appropriate who 
     have experience providing home-based primary care to 
     applicable beneficiaries, make in-home visits, and are 
     available 24 hours per day, 7 days per week to carry out 
     plans of care that are tailored to the individual 
     beneficiary's chronic conditions and designed to achieve the 
     results in subsection (a);
       ``(ii) is organized at least in part for the purpose of 
     providing physicians' services;
       ``(iii) has documented experience in providing home-based 
     primary care services to high-cost chronically ill 
     beneficiaries, as determined appropriate by the Secretary;
       ``(iv) furnishes services to at least 200 applicable 
     beneficiaries (as defined in subsection (d)) during each year 
     of the demonstration program;
       ``(v) has entered into an agreement with the Secretary;
       ``(vi) uses electronic health information systems, remote 
     monitoring, and mobile diagnostic technology; and
       ``(vii) meets such other criteria as the Secretary 
     determines to be appropriate to participate in the 
     demonstration program.
     The entity shall report on quality measures (in such form, 
     manner, and frequency as specified by the Secretary, which 
     may be for the group, for providers of services and 
     suppliers, or both) and report to the Secretary (in a form, 
     manner, and frequency as specified by the Secretary) such 
     data as the Secretary determines appropriate to monitor and 
     evaluate the demonstration program.
       ``(B) Physician.--The term `physician' includes, except as 
     the Secretary may otherwise provide, any individual who 
     furnishes services for which payment may be made as 
     physicians' services and has the medical training or 
     experience to fulfill the physician's role described in 
     subparagraph (A)(i).
       ``(2) Participation of nurse practitioners and physician 
     assistants.--Nothing in this section shall be construed to 
     prevent a nurse practitioner or physician assistant from 
     participating in, or leading, a home-based primary care team 
     as part of an independence at home medical practice if--
       ``(A) all the requirements of this section are met;
       ``(B) the nurse practitioner or physician assistant, as the 
     case may be, is acting consistent with State law; and
       ``(C) the nurse practitioner or physician assistant has the 
     medical training or experience to fulfill the nurse 
     practitioner or physician assistant role described in 
     paragraph (1)(A)(i).
       ``(3) Inclusion of providers and practitioners.--Nothing in 
     this subsection shall be construed as preventing an 
     independence at home medical practice from including a 
     provider of services or a participating practitioner 
     described in section 1842(b)(18)(C) that is affiliated with 
     the practice under an arrangement structured so that such 
     provider of services or practitioner participates in the 
     demonstration program and shares in any savings under the 
     demonstration program.
       ``(4) Quality and performance standards.--The Secretary 
     shall develop quality performance standards for independence 
     at home medical practices participating in the demonstration 
     program.
       ``(c) Payment Methodology.--
       ``(1) Establishment of target spending level.--The 
     Secretary shall establish an estimated annual spending 
     target, for the amount the Secretary estimates would have 
     been spent in the absence of the demonstration, for items and 
     services covered under parts A and B furnished to applicable 
     beneficiaries for each qualifying independence at home 
     medical practice under this section. Such spending targets 
     shall be determined on a per capita basis. Such spending 
     targets shall include a risk corridor that takes into account 
     normal variation in expenditures for items and services 
     covered under parts A and B furnished to such beneficiaries 
     with the size of the corridor being related to the number of 
     applicable beneficiaries furnished services by each 
     independence at home medical practice. The spending targets 
     may also be adjusted for other factors as the Secretary 
     determines appropriate.
       ``(2) Incentive payments.--Subject to performance on 
     quality measures, a qualifying independence at home medical 
     practice is eligible to receive an incentive payment under 
     this section if actual expenditures for a year for the 
     applicable beneficiaries it enrolls are less than the 
     estimated spending target established under paragraph (1) for 
     such year. An incentive payment for such year shall be equal 
     to a portion (as determined by the Secretary) of the amount 
     by which actual expenditures (including incentive payments 
     under this paragraph) for applicable beneficiaries under 
     parts A and B for such year are estimated to be less than 5 
     percent less than the estimated spending target for such 
     year, as determined under paragraph (1).
       ``(d) Applicable Beneficiaries.--
       ``(1) Definition.--In this section, the term `applicable 
     beneficiary' means, with respect to a qualifying independence 
     at home medical practice, an individual who the practice has 
     determined--
       ``(A) is entitled to benefits under part A and enrolled for 
     benefits under part B;
       ``(B) is not enrolled in a Medicare Advantage plan under 
     part C or a PACE program under section 1894;
       ``(C) has 2 or more chronic illnesses, such as congestive 
     heart failure, diabetes, other dementias designated by the 
     Secretary, chronic obstructive pulmonary disease, ischemic 
     heart disease, stroke, Alzheimer's Disease and 
     neurodegenerative diseases, and other diseases and conditions 
     designated by the Secretary which result in high costs under 
     this title;
       ``(D) within the past 12 months has had a nonelective 
     hospital admission;
       ``(E) within the past 12 months has received acute or 
     subacute rehabilitation services;
       ``(F) has 2 or more functional dependencies requiring the 
     assistance of another person (such as bathing, dressing, 
     toileting, walking, or feeding); and
       ``(G) meets such other criteria as the Secretary determines 
     appropriate.
       ``(2) Patient election to participate.--The Secretary shall 
     determine an appropriate method of ensuring that applicable 
     beneficiaries have agreed to enroll in an independence at 
     home medical practice under the demonstration program. 
     Enrollment in the demonstration program shall be voluntary.
       ``(3) Beneficiary access to services.--Nothing in this 
     section shall be construed as encouraging physicians or nurse 
     practitioners to limit applicable beneficiary access to 
     services covered under this title and applicable 
     beneficiaries shall not be required to relinquish access to 
     any benefit under this title as a condition of receiving 
     services from an independence at home medical practice.
       ``(e) Implementation.--
       ``(1) Starting date.--The demonstration program shall begin 
     no later than January 1, 2012. An agreement with an 
     independence at home medical practice under the demonstration 
     program may cover not more than a 3-year period.
       ``(2) No physician duplication in demonstration 
     participation.--The Secretary shall not pay an independence 
     at home medical practice under this section that participates 
     in section 1899.
       ``(3) No beneficiary duplication in demonstration 
     participation.--The Secretary shall ensure that no applicable 
     beneficiary enrolled in an independence at home medical 
     practice under this section is participating in the programs 
     under section 1899.
       ``(4) Preference.--In approving an independence at home 
     medical practice, the Secretary shall give preference to 
     practices that are--
       ``(A) located in high-cost areas of the country;
       ``(B) have experience in furnishing health care services to 
     applicable beneficiaries in the home; and
       ``(C) use electronic medical records, health information 
     technology, and individualized plans of care.
       ``(5) Limitation on number of practices.--In selecting 
     qualified independence at home medical practices to 
     participate under the demonstration program, the Secretary 
     shall limit the number of such practices so that the number 
     of applicable beneficiaries that may participate in the 
     demonstration program does not exceed 10,000.
       ``(6) Waiver.--The Secretary may waive such provisions of 
     this title and title XI as the Secretary determines necessary 
     in order to implement the demonstration program.
       ``(7) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to this section.
       ``(f) Evaluation and Monitoring.--
       ``(1) In general.--The Secretary shall evaluate each 
     independence at home medical practice under the demonstration 
     program to assess whether the practice achieved the results 
     described in subsection (a).
       ``(2) Monitoring applicable beneficiaries.--The Secretary 
     may monitor data on expenditures and quality of services 
     under this title after an applicable beneficiary discontinues 
     receiving services under this title through a qualifying 
     independence at home medical practice.
       ``(g) Reports to Congress.--The Secretary shall conduct an 
     independent evaluation of the demonstration program and 
     submit to Congress a final report, including best practices 
     under the demonstration program. Such report shall include an 
     analysis of the demonstration program on coordination of 
     care, expenditures under this title, applicable beneficiary 
     access to services, and the quality of health care services 
     provided to applicable beneficiaries.
       ``(h) Funding.--For purposes of administering and carrying 
     out the demonstration program, other than for payments for 
     items and services furnished under this title and incentive 
     payments under subsection (c), in addition to funds otherwise 
     appropriated, there shall be transferred to the Secretary for 
     the Center for Medicare & Medicaid Services Program 
     Management Account from the Federal Hospital Insurance Trust 
     Fund under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841 (in proportions 
     determined appropriate by the Secretary) $5,000,000 for each 
     of fiscal years 2010 through 2015. Amounts transferred under 
     this subsection for a fiscal year shall be available until 
     expended.
       ``(i) Termination.--
       ``(1) Mandatory termination.--The Secretary shall terminate 
     an agreement with an independence at home medical practice 
     if--
       ``(A) the Secretary estimates or determines that such 
     practice will not receive an incentive

[[Page 4281]]

     payment for the second of 2 consecutive years under the 
     demonstration program; or
       ``(B) such practice fails to meet quality standards during 
     any year of the demonstration program.
       ``(2) Permissive termination.--The Secretary may terminate 
     an agreement with an independence at home medical practice 
     for such other reasons determined appropriate by the 
     Secretary.''.

     SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM.

       (a) In General.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww), as amended by sections 3001 and 3008, is 
     amended by adding at the end the following new subsection:
       ``(q) Hospital Readmissions Reduction Program.--
       ``(1) In general.--With respect to payment for discharges 
     from an applicable hospital (as defined in paragraph (5)(C)) 
     occurring during a fiscal year beginning on or after October 
     1, 2012, in order to account for excess readmissions in the 
     hospital, the Secretary shall reduce the payments that would 
     otherwise be made to such hospital under subsection (d) (or 
     section 1814(b)(3), as the case may be) for such a discharge 
     by an amount equal to the product of--
       ``(A) the base operating DRG payment amount (as defined in 
     paragraph (2)) for the discharge; and
       ``(B) the adjustment factor (described in paragraph (3)(A)) 
     for the hospital for the fiscal year.
       ``(2) Base operating drg payment amount defined.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     in this subsection, the term `base operating DRG payment 
     amount' means, with respect to a hospital for a fiscal year--
       ``(i) the payment amount that would otherwise be made under 
     subsection (d) (determined without regard to subsection (o)) 
     for a discharge if this subsection did not apply; reduced by
       ``(ii) any portion of such payment amount that is 
     attributable to payments under paragraphs (5)(A), (5)(B), 
     (5)(F), and (12) of subsection (d).
       ``(B) Special rules for certain hospitals.--
       ``(i) Sole community hospitals and medicare-dependent, 
     small rural hospitals.--In the case of a medicare-dependent, 
     small rural hospital (with respect to discharges occurring 
     during fiscal years 2012 and 2013) or a sole community 
     hospital, in applying subparagraph (A)(i), the payment amount 
     that would otherwise be made under subsection (d) shall be 
     determined without regard to subparagraphs (I) and (L) of 
     subsection (b)(3) and subparagraphs (D) and (G) of subsection 
     (d)(5).
       ``(ii) Hospitals paid under section 1814.--In the case of a 
     hospital that is paid under section 1814(b)(3), the Secretary 
     may exempt such hospitals provided that States paid under 
     such section submit an annual report to the Secretary 
     describing how a similar program in the State for a 
     participating hospital or hospitals achieves or surpasses the 
     measured results in terms of patient health outcomes and cost 
     savings established herein with respect to this section.
       ``(3) Adjustment factor.--
       ``(A) In general.--For purposes of paragraph (1), the 
     adjustment factor under this paragraph for an applicable 
     hospital for a fiscal year is equal to the greater of--
       ``(i) the ratio described in subparagraph (B) for the 
     hospital for the applicable period (as defined in paragraph 
     (5)(D)) for such fiscal year; or
       ``(ii) the floor adjustment factor specified in 
     subparagraph (C).
       ``(B) Ratio.--The ratio described in this subparagraph for 
     a hospital for an applicable period is equal to 1 minus the 
     ratio of--
       ``(i) the aggregate payments for excess readmissions (as 
     defined in paragraph (4)(A)) with respect to an applicable 
     hospital for the applicable period; and
       ``(ii) the aggregate payments for all discharges (as 
     defined in paragraph (4)(B)) with respect to such applicable 
     hospital for such applicable period.
       ``(C) Floor adjustment factor.--For purposes of 
     subparagraph (A), the floor adjustment factor specified in 
     this subparagraph for--
       ``(i) fiscal year 2013 is 0.99;
       ``(ii) fiscal year 2014 is 0.98; or
       ``(iii) fiscal year 2015 and subsequent fiscal years is 
     0.97.
       ``(4) Aggregate payments, excess readmission ratio 
     defined.--For purposes of this subsection:
       ``(A) Aggregate payments for excess readmissions.--The term 
     `aggregate payments for excess readmissions' means, for a 
     hospital for an applicable period, the sum, for applicable 
     conditions (as defined in paragraph (5)(A)), of the product, 
     for each applicable condition, of--
       ``(i) the base operating DRG payment amount for such 
     hospital for such applicable period for such condition;
       ``(ii) the number of admissions for such condition for such 
     hospital for such applicable period; and
       ``(iii) the excess readmissions ratio (as defined in 
     subparagraph (C)) for such hospital for such applicable 
     period minus 1.
       ``(B) Aggregate payments for all discharges.--The term 
     `aggregate payments for all discharges' means, for a hospital 
     for an applicable period, the sum of the base operating DRG 
     payment amounts for all discharges for all conditions from 
     such hospital for such applicable period.
       ``(C) Excess readmission ratio.--
       ``(i) In general.--Subject to clause (ii), the term `excess 
     readmissions ratio' means, with respect to an applicable 
     condition for a hospital for an applicable period, the ratio 
     (but not less than 1.0) of--

       ``(I) the risk adjusted readmissions based on actual 
     readmissions, as determined consistent with a readmission 
     measure methodology that has been endorsed under paragraph 
     (5)(A)(ii)(I), for an applicable hospital for such condition 
     with respect to such applicable period; to
       ``(II) the risk adjusted expected readmissions (as 
     determined consistent with such a methodology) for such 
     hospital for such condition with respect to such applicable 
     period.

       ``(ii) Exclusion of certain readmissions.--For purposes of 
     clause (i), with respect to a hospital, excess readmissions 
     shall not include readmissions for an applicable condition 
     for which there are fewer than a minimum number (as 
     determined by the Secretary) of discharges for such 
     applicable condition for the applicable period and such 
     hospital.
       ``(5) Definitions.--For purposes of this subsection:
       ``(A) Applicable condition.--The term `applicable 
     condition' means, subject to subparagraph (B), a condition or 
     procedure selected by the Secretary among conditions and 
     procedures for which--
       ``(i) readmissions (as defined in subparagraph (E)) that 
     represent conditions or procedures that are high volume or 
     high expenditures under this title (or other criteria 
     specified by the Secretary); and
       ``(ii) measures of such readmissions--

       ``(I) have been endorsed by the entity with a contract 
     under section 1890(a); and
       ``(II) such endorsed measures have exclusions for 
     readmissions that are unrelated to the prior discharge (such 
     as a planned readmission or transfer to another applicable 
     hospital).

       ``(B) Expansion of applicable conditions.--Beginning with 
     fiscal year 2015, the Secretary shall, to the extent 
     practicable, expand the applicable conditions beyond the 3 
     conditions for which measures have been endorsed as described 
     in subparagraph (A)(ii)(I) as of the date of the enactment of 
     this subsection to the additional 4 conditions that have been 
     identified by the Medicare Payment Advisory Commission in its 
     report to Congress in June 2007 and to other conditions and 
     procedures as determined appropriate by the Secretary. In 
     expanding such applicable conditions, the Secretary shall 
     seek the endorsement described in subparagraph (A)(ii)(I) but 
     may apply such measures without such an endorsement in the 
     case of a specified area or medical topic determined 
     appropriate by the Secretary for which a feasible and 
     practical measure has not been endorsed by the entity with a 
     contract under section 1890(a) as long as due consideration 
     is given to measures that have been endorsed or adopted by a 
     consensus organization identified by the Secretary.
       ``(C) Applicable hospital.--The term `applicable hospital' 
     means a subsection (d) hospital or a hospital that is paid 
     under section 1814(b)(3), as the case may be.
       ``(D) Applicable period.--The term `applicable period' 
     means, with respect to a fiscal year, such period as the 
     Secretary shall specify.
       ``(E) Readmission.--The term `readmission' means, in the 
     case of an individual who is discharged from an applicable 
     hospital, the admission of the individual to the same or 
     another applicable hospital within a time period specified by 
     the Secretary from the date of such discharge. Insofar as the 
     discharge relates to an applicable condition for which there 
     is an endorsed measure described in subparagraph (A)(ii)(I), 
     such time period (such as 30 days) shall be consistent with 
     the time period specified for such measure.
       ``(6) Reporting hospital specific information.--
       ``(A) In general.--The Secretary shall make information 
     available to the public regarding readmission rates of each 
     subsection (d) hospital under the program.
       ``(B) Opportunity to review and submit corrections.--The 
     Secretary shall ensure that a subsection (d) hospital has the 
     opportunity to review, and submit corrections for, the 
     information to be made public with respect to the hospital 
     under subparagraph (A) prior to such information being made 
     public.
       ``(C) Website.--Such information shall be posted on the 
     Hospital Compare Internet website in an easily understandable 
     format.
       ``(7) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the following:
       ``(A) The determination of base operating DRG payment 
     amounts.
       ``(B) The methodology for determining the adjustment factor 
     under paragraph (3), including excess readmissions ratio 
     under paragraph (4)(C), aggregate payments for excess 
     readmissions under paragraph (4)(A), and aggregate payments 
     for all discharges under paragraph (4)(B), and applicable 
     periods and applicable conditions under paragraph (5).
       ``(C) The measures of readmissions as described in 
     paragraph (5)(A)(ii).
       ``(8) Readmission rates for all patients.--
       ``(A) Calculation of readmission.--The Secretary shall 
     calculate readmission rates for all patients (as defined in 
     subparagraph (D)) for a specified hospital (as defined in 
     subparagraph (D)(ii)) for an applicable condition (as defined 
     in paragraph (5)(B)) and other conditions deemed appropriate 
     by the Secretary for an applicable period (as defined in 
     paragraph (5)(D)) in the same manner as used to calculate 
     such readmission rates for hospitals with respect to this 
     title and posted on the CMS Hospital Compare website.

[[Page 4282]]

       ``(B) Posting of hospital specific all patient readmission 
     rates.--The Secretary shall make information on all patient 
     readmission rates calculated under subparagraph (A) available 
     on the CMS Hospital Compare website in a form and manner 
     determined appropriate by the Secretary. The Secretary may 
     also make other information determined appropriate by the 
     Secretary available on such website.
       ``(C) Hospital submission of all patient data.--
       ``(i) Except as provided for in clause (ii), each specified 
     hospital (as defined in subparagraph (D)(ii)) shall submit to 
     the Secretary, in a form, manner and time specified by the 
     Secretary, data and information determined necessary by the 
     Secretary for the Secretary to calculate the all patient 
     readmission rates described in subparagraph (A).
       ``(ii) Instead of a specified hospital submitting to the 
     Secretary the data and information described in clause (i), 
     such data and information may be submitted to the Secretary, 
     on behalf of such a specified hospital, by a state or an 
     entity determined appropriate by the Secretary.
       ``(D) Definitions.--For purposes of this paragraph:
       ``(i) The term `all patients' means patients who are 
     treated on an inpatient basis and discharged from a specified 
     hospital (as defined in clause (ii)).
       ``(ii) The term `specified hospital' means a subsection (d) 
     hospital, hospitals described in clauses (i) through (v) of 
     subsection (d)(1)(B) and, as determined feasible and 
     appropriate by the Secretary, other hospitals not otherwise 
     described in this subparagraph.''.
       (b) Quality Improvement.--Part S of title III of the Public 
     Health Service Act, as amended by section 3015, is further 
     amended by adding at the end the following:

     ``SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS WITH 
                   A HIGH SEVERITY ADJUSTED READMISSION RATE.

       ``(a) Establishment.--
       ``(1) In general.--Not later than 2 years after the date of 
     enactment of this section, the Secretary shall make available 
     a program for eligible hospitals to improve their readmission 
     rates through the use of patient safety organizations (as 
     defined in section 921(4)).
       ``(2) Eligible hospital defined.--In this subsection, the 
     term `eligible hospital' means a hospital that the Secretary 
     determines has a high rate of risk adjusted readmissions for 
     the conditions described in section 1886(q)(8)(A) of the 
     Social Security Act and has not taken appropriate steps to 
     reduce such readmissions and improve patient safety as 
     evidenced through historically high rates of readmissions, as 
     determined by the Secretary.
       ``(3) Risk adjustment.--The Secretary shall utilize 
     appropriate risk adjustment measures to determine eligible 
     hospitals.
       ``(b) Report to the Secretary.--As determined appropriate 
     by the Secretary, eligible hospitals and patient safety 
     organizations working with those hospitals shall report to 
     the Secretary on the processes employed by the hospital to 
     improve readmission rates and the impact of such processes on 
     readmission rates.''.

     SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM.

       (a) In General.--The Secretary shall establish a Community-
     Based Care Transitions Program under which the Secretary 
     provides funding to eligible entities that furnish improved 
     care transition services to high-risk Medicare beneficiaries.
       (b) Definitions.--In this section:
       (1) Eligible entity.--The term ``eligible entity'' means 
     the following:
       (A) A subsection (d) hospital (as defined in section 
     1886(d)(1)(B) of the Social Security Act (42 U.S.C. 
     1395ww(d)(1)(B))) identified by the Secretary as having a 
     high readmission rate, such as under section 1886(q) of the 
     Social Security Act, as added by section 3025.
       (B) An appropriate community-based organization that 
     provides care transition services under this section across a 
     continuum of care through arrangements with subsection (d) 
     hospitals (as so defined) to furnish the services described 
     in subsection (c)(2)(B)(i) and whose governing body includes 
     sufficient representation of multiple health care 
     stakeholders (including consumers).
       (2) High-risk medicare beneficiary.--The term ``high-risk 
     Medicare beneficiary'' means a Medicare beneficiary who has 
     attained a minimum hierarchical condition category score, as 
     determined by the Secretary, based on a diagnosis of multiple 
     chronic conditions or other risk factors associated with a 
     hospital readmission or substandard transition into post-
     hospitalization care, which may include 1 or more of the 
     following:
       (A) Cognitive impairment.
       (B) Depression.
       (C) A history of multiple readmissions.
       (D) Any other chronic disease or risk factor as determined 
     by the Secretary.
       (3) Medicare beneficiary.--The term ``Medicare 
     beneficiary'' means an individual who is entitled to benefits 
     under part A of title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.) and enrolled under part B of such title, 
     but not enrolled under part C of such title.
       (4) Program.--The term ``program'' means the program 
     conducted under this section.
       (5) Readmission.--The term ``readmission'' has the meaning 
     given such term in section 1886(q)(5)(E) of the Social 
     Security Act, as added by section 3025.
       (6) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (c) Requirements.--
       (1) Duration.--
       (A) In general.--The program shall be conducted for a 5-
     year period, beginning January 1, 2011.
       (B) Expansion.--The Secretary may expand the duration and 
     the scope of the program, to the extent determined 
     appropriate by the Secretary, if the Secretary determines 
     (and the Chief Actuary of the Centers for Medicare & Medicaid 
     Services, with respect to spending under this title, 
     certifies) that such expansion would reduce spending under 
     this title without reducing quality.
       (2) Application; participation.--
       (A) In general.--
       (i) Application.--An eligible entity seeking to participate 
     in the program shall submit an application to the Secretary 
     at such time, in such manner, and containing such information 
     as the Secretary may require.
       (ii) Partnership.--If an eligible entity is a hospital, 
     such hospital shall enter into a partnership with a 
     community-based organization to participate in the program.
       (B) Intervention proposal.--Subject to subparagraph (C), an 
     application submitted under subparagraph (A)(i) shall include 
     a detailed proposal for at least 1 care transition 
     intervention, which may include the following:
       (i) Initiating care transition services for a high-risk 
     Medicare beneficiary not later than 24 hours prior to the 
     discharge of the beneficiary from the eligible entity.
       (ii) Arranging timely post-discharge follow-up services to 
     the high-risk Medicare beneficiary to provide the beneficiary 
     (and, as appropriate, the primary caregiver of the 
     beneficiary) with information regarding responding to 
     symptoms that may indicate additional health problems or a 
     deteriorating condition.
       (iii) Providing the high-risk Medicare beneficiary (and, as 
     appropriate, the primary caregiver of the beneficiary) with 
     assistance to ensure productive and timely interactions 
     between patients and post-acute and outpatient providers.
       (iv) Assessing and actively engaging with a high-risk 
     Medicare beneficiary (and, as appropriate, the primary 
     caregiver of the beneficiary) through the provision of self-
     management support and relevant information that is specific 
     to the beneficiary's condition.
       (v) Conducting comprehensive medication review and 
     management (including, if appropriate, counseling and self-
     management support).
       (C) Limitation.--A care transition intervention proposed 
     under subparagraph (B) may not include payment for services 
     required under the discharge planning process described in 
     section 1861(ee) of the Social Security Act (42 U.S.C. 
     1395x(ee)).
       (3) Selection.--In selecting eligible entities to 
     participate in the program, the Secretary shall give priority 
     to eligible entities that--
       (A) participate in a program administered by the 
     Administration on Aging to provide concurrent care 
     transitions interventions with multiple hospitals and 
     practitioners; or
       (B) provide services to medically underserved populations, 
     small communities, and rural areas.
       (d) Implementation.--Notwithstanding any other provision of 
     law, the Secretary may implement the provisions of this 
     section by program instruction or otherwise.
       (e) Waiver Authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act as may be necessary to carry out the program.
       (f) Funding.--For purposes of carrying out this section, 
     the Secretary of Health and Human Services shall provide for 
     the transfer, from the Federal Hospital Insurance Trust Fund 
     under section 1817 of the Social Security Act (42 U.S.C. 
     1395i) and the Federal Supplementary Medical Insurance Trust 
     Fund under section 1841 of such Act (42 U.S.C. 1395t), in 
     such proportion as the Secretary determines appropriate, of 
     $500,000,000, to the Centers for Medicare & Medicaid Services 
     Program Management Account for the period of fiscal years 
     2011 through 2015. Amounts transferred under the preceding 
     sentence shall remain available until expended.

     SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION.

       (a) In General.--Subsection (d)(3) of section 5007 of the 
     Deficit Reduction Act of 2005 (Public Law 109-171) is amended 
     by inserting ``(or September 30, 2011, in the case of a 
     demonstration project in operation as of October 1, 2008)'' 
     after ``December 31, 2009''.
       (b) Funding.--
       (1) In general.--Subsection (f)(1) of such section is 
     amended by inserting ``and for fiscal year 2010, 
     $1,600,000,'' after ``$6,000,000,''.
       (2) Availability.--Subsection (f)(2) of such section is 
     amended by striking ``2010'' and inserting ``2014 or until 
     expended''.
       (c) Reports.--
       (1) Quality improvement and savings.--Subsection (e)(3) of 
     such section is amended by striking ``December 1, 2008'' and 
     inserting ``March 31, 2011''.
       (2) Final report.--Subsection (e)(4) of such section is 
     amended by striking ``May 1, 2010'' and inserting ``March 31, 
     2013''.

       Subtitle B--Improving Medicare for Patients and Providers

    PART I--ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER 
                                SERVICES

     SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE.

       Section 1848(d) of the Social Security Act (42 U.S.C. 
     1395w-4(d)) is amended by adding at the end the following new 
     paragraph:

[[Page 4283]]

       ``(10) Update for 2010.--
       ``(A) In general.--Subject to paragraphs (7)(B), (8)(B), 
     and (9)(B), in lieu of the update to the single conversion 
     factor established in paragraph (1)(C) that would otherwise 
     apply for 2010, the update to the single conversion factor 
     shall be 0.5 percent.
       ``(B) No effect on computation of conversion factor for 
     2011 and subsequent years.--The conversion factor under this 
     subsection shall be computed under paragraph (1)(A) for 2011 
     and subsequent years as if subparagraph (A) had never 
     applied.''.

     SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND 
                   REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC 
                   ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 
                   SCHEDULE.

       (a) Extension of Work GPCI Floor.--Section 1848(e)(1)(E) of 
     the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is 
     amended by striking ``before January 1, 2010'' and inserting 
     ``before January 1, 2011''.
       (b) Practice Expense Geographic Adjustment for 2010 and 
     Subsequent Years.--Section 1848(e)(1) of the Social Security 
     Act (42 U.S.C. 1395w4(e)(1)) is amended--
       (1) in subparagraph (A), by striking ``and (G)'' and 
     inserting ``(G), and (H)''; and
       (2) by adding at the end the following new subparagraph:
       ``(H) Practice expense geographic adjustment for 2010 and 
     subsequent years.--
       ``(i) For 2010.--Subject to clause (iii), for services 
     furnished during 2010, the employee wage and rent portions of 
     the practice expense geographic index described in 
     subparagraph (A)(i) shall reflect \3/4\ of the difference 
     between the relative costs of employee wages and rents in 
     each of the different fee schedule areas and the national 
     average of such employee wages and rents.
       ``(ii) For 2011.--Subject to clause (iii), for services 
     furnished during 2011, the employee wage and rent portions of 
     the practice expense geographic index described in 
     subparagraph (A)(i) shall reflect \1/2\ of the difference 
     between the relative costs of employee wages and rents in 
     each of the different fee schedule areas and the national 
     average of such employee wages and rents.
       ``(iii) Hold harmless.--The practice expense portion of the 
     geographic adjustment factor applied in a fee schedule area 
     for services furnished in 2010 or 2011 shall not, as a result 
     of the application of clause (i) or (ii), be reduced below 
     the practice expense portion of the geographic adjustment 
     factor under subparagraph (A)(i) (as calculated prior to the 
     application of such clause (i) or (ii), respectively) for 
     such area for such year.
       ``(iv) Analysis.--The Secretary shall analyze current 
     methods of establishing practice expense geographic 
     adjustments under subparagraph (A)(i) and evaluate data that 
     fairly and reliably establishes distinctions in the costs of 
     operating a medical practice in the different fee schedule 
     areas. Such analysis shall include an evaluation of the 
     following:

       ``(I) The feasibility of using actual data or reliable 
     survey data developed by medical organizations on the costs 
     of operating a medical practice, including office rents and 
     non-physician staff wages, in different fee schedule areas.
       ``(II) The office expense portion of the practice expense 
     geographic adjustment described in subparagraph (A)(i), 
     including the extent to which types of office expenses are 
     determined in local markets instead of national markets.
       ``(III) The weights assigned to each of the categories 
     within the practice expense geographic adjustment described 
     in subparagraph (A)(i).

       ``(v) Revision for 2012 and subsequent years.--As a result 
     of the analysis described in clause (iv), the Secretary 
     shall, not later than January 1, 2012, make appropriate 
     adjustments to the practice expense geographic adjustment 
     described in subparagraph (A)(i) to ensure accurate 
     geographic adjustments across fee schedule areas, including--

       ``(I) basing the office rents component and its weight on 
     office expenses that vary among fee schedule areas; and
       ``(II) considering a representative range of professional 
     and non-professional personnel employed in a medical office 
     based on the use of the American Community Survey data or 
     other reliable data for wage adjustments.

     Such adjustments shall be made without regard to adjustments 
     made pursuant to clauses (i) and (ii) and shall be made in a 
     budget neutral manner.''.

     SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE 
                   THERAPY CAPS.

       Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
     1395l(g)(5)) is amended by striking ``December 31, 2009'' and 
     inserting ``December 31, 2010''.

     SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 
                   CERTAIN PHYSICIAN PATHOLOGY SERVICES.

       Section 542(c) of the Medicare, Medicaid, and SCHIP 
     Benefits Improvement and Protection Act of 2000 (as enacted 
     into law by section 1(a)(6) of Public Law 106-554), as 
     amended by section 732 of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4 
     note), section 104 of division B of the Tax Relief and Health 
     Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the 
     Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
     Law 110-173), and section 136 of the Medicare Improvements 
     for Patients and Providers Act of 2008 (Public Law 110-275), 
     is amended by striking ``and 2009'' and inserting ``2009, and 
     2010''.

     SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS.

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

     SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM 
                   CARE HOSPITAL SERVICES AND OF MORATORIUM ON THE 
                   ESTABLISHMENT OF CERTAIN HOSPITALS AND 
                   FACILITIES.

       (a) Extension of Certain Payment Rules.--Section 114(c) of 
     the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 
     U.S.C. 1395ww note), as amended by section 4302(a) of the 
     American Recovery and Reinvestment Act (Public Law 111-5), is 
     further amended by striking ``3-year period'' each place it 
     appears and inserting ``4-year period''.
       (b) Extension of Moratorium.--Section 114(d)(1) of such Act 
     (42 U.S.C. 1395ww note), in the matter preceding subparagraph 
     (A), is amended by striking ``3-year period'' and inserting 
     ``4-year period''.

     SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH 
                   ADD-ON.

       Section 138(a)(1) of the Medicare Improvements for Patients 
     and Providers Act of 2008 (Public Law 110-275) is amended by 
     striking ``December 31, 2009'' and inserting ``December 31, 
     2010''.

     SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-
                   HOSPITAL EXTENDED CARE SERVICES.

       (a) Ordering Post-Hospital Extended Care Services.--
       (1) In general.--Section 1814(a)(2) of the Social Security 
     Act (42 U.S.C. 1395f(a)(2)), in the matter preceding 
     subparagraph (A), is amended by striking ``or clinical nurse 
     specialist'' and inserting ``, a clinical nurse specialist, 
     or a physician assistant (as those terms are defined in 
     section 1861(aa)(5))'' after ``nurse practitioner''.
       (2) Conforming amendment.--Section 1814(a) of the Social 
     Security Act (42 U.S.C. 1395f(a)) is amended, in the second 
     sentence, by striking ``or clinical nurse specialist'' and 
     inserting ``clinical nurse specialist, or physician 
     assistant'' after ``nurse practitioner,''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.

     SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION 
                   REQUIREMENTS.

       (a) In General.--Section 1834(a)(20) of the Social Security 
     Act (42 U.S.C. 1395m(a)(20)), as added by section 
     154(b)(1)(A) of the Medicare Improvements for Patients and 
     Providers Act of 2008 (Public Law 100-275), is amended--
       (1) in subparagraph (F)(i)--
       (A) by inserting ``and subparagraph (G)'' after ``clause 
     (ii)''; and
       (B) by inserting ``, except that the Secretary shall not 
     require a pharmacy to have submitted to the Secretary such 
     evidence of accreditation prior to January 1, 2011'' before 
     the semicolon at the end; and
       (2) by adding at the end the following new subparagraph:
       ``(G) Application of accreditation requirement to certain 
     pharmacies.--
       ``(i) In general.--With respect to items and services 
     furnished on or after January 1, 2011, in implementing 
     quality standards under this paragraph--

       ``(I) subject to subclause (II), in applying such standards 
     and the accreditation requirement of subparagraph (F)(i) with 
     respect to pharmacies described in clause (ii) furnishing 
     such items and services, such standards and accreditation 
     requirement shall not apply to such pharmacies; and
       ``(II) the Secretary may apply to such pharmacies an 
     alternative accreditation requirement established by the 
     Secretary if the Secretary determines such alternative 
     accreditation requirement is more appropriate for such 
     pharmacies.

       ``(ii) Pharmacies described.--A pharmacy described in this 
     clause is a pharmacy that meets each of the following 
     criteria:

       ``(I) The total billings by the pharmacy for such items and 
     services under this title are less than 5 percent of total 
     pharmacy sales, as determined based on the average total 
     pharmacy sales for the previous 3 calendar years, 3 fiscal 
     years, or other yearly period specified by the Secretary.
       ``(II) The pharmacy has been enrolled under section 1866(j) 
     as a supplier of durable medical equipment, prosthetics, 
     orthotics, and supplies, has been issued (which may include 
     the renewal of) a provider number for at least 5 years, and 
     for which a final adverse action (as defined in section 
     424.57(a) of title 42, Code of Federal Regulations) has not 
     been imposed in the past 5 years.

[[Page 4284]]

       ``(III) The pharmacy submits to the Secretary an 
     attestation, in a form and manner, and at a time, specified 
     by the Secretary, that the pharmacy meets the criteria 
     described in subclauses (I) and (II). Such attestation shall 
     be subject to section 1001 of title 18, United States Code.
       ``(IV) The pharmacy agrees to submit materials as requested 
     by the Secretary, or during the course of an audit conducted 
     on a random sample of pharmacies selected annually, to verify 
     that the pharmacy meets the criteria described in subclauses 
     (I) and (II). Materials submitted under the preceding 
     sentence shall include a certification by an accountant on 
     behalf of the pharmacy or the submission of tax returns filed 
     by the pharmacy during the relevant periods, as requested by 
     the Secretary.''.

       (b) Administration.--Notwithstanding any other provision of 
     law, the Secretary may implement the amendments made by 
     subsection (a) by program instruction or otherwise.
       (c) Rule of Construction.--Nothing in the provisions of or 
     amendments made by this section shall be construed as 
     affecting the application of an accreditation requirement for 
     pharmacies to qualify for bidding in a competitive 
     acquisition area under section 1847 of the Social Security 
     Act (42 U.S.C. 1395w-3).

     SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED 
                   TRICARE BENEFICIARIES.

       (a) In General.--
       (1) In general.--Section 1837 of the Social Security Act 
     (42 U.S.C. 1395p) is amended by adding at the end the 
     following new subsection:
       ``(l)(1) In the case of any individual who is a covered 
     beneficiary (as defined in section 1072(5) of title 10, 
     United States Code) at the time the individual is entitled to 
     part A under section 226(b) or section 226A and who is 
     eligible to enroll but who has elected not to enroll (or to 
     be deemed enrolled) during the individual's initial 
     enrollment period, there shall be a special enrollment period 
     described in paragraph (2).
       ``(2) The special enrollment period described in this 
     paragraph, with respect to an individual, is the 12-month 
     period beginning on the day after the last day of the initial 
     enrollment period of the individual or, if later, the 12-
     month period beginning with the month the individual is 
     notified of enrollment under this section.
       ``(3) In the case of an individual who enrolls during the 
     special enrollment period provided under paragraph (1), the 
     coverage period under this part shall begin on the first day 
     of the month in which the individual enrolls, or, at the 
     option of the individual, the first month after the end of 
     the individual's initial enrollment period.
       ``(4) An individual may only enroll during the special 
     enrollment period provided under paragraph (1) one time 
     during the individual's lifetime.
       ``(5) The Secretary shall ensure that the materials 
     relating to coverage under this part that are provided to an 
     individual described in paragraph (1) prior to the 
     individual's initial enrollment period contain information 
     concerning the impact of not enrolling under this part, 
     including the impact on health care benefits under the 
     TRICARE program under chapter 55 of title 10, United States 
     Code.
       ``(6) The Secretary of Defense shall collaborate with the 
     Secretary of Health and Human Services and the Commissioner 
     of Social Security to provide for the accurate identification 
     of individuals described in paragraph (1). The Secretary of 
     Defense shall provide such individuals with notification with 
     respect to this subsection. The Secretary of Defense shall 
     collaborate with the Secretary of Health and Human Services 
     and the Commissioner of Social Security to ensure appropriate 
     follow up pursuant to any notification provided under the 
     preceding sentence.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to elections made with respect to initial 
     enrollment periods that end after the date of the enactment 
     of this Act.
       (b) Waiver of Increase of Premium.--Section 1839(b) of the 
     Social Security Act (42 U.S.C. 1395r(b)) is amended by 
     striking ``section 1837(i)(4)'' and inserting ``subsection 
     (i)(4) or (l) of section 1837''.

     SEC. 3111. PAYMENT FOR BONE DENSITY TESTS.

       (a) Payment.--
       (1) In general.--Section 1848 of the Social Security Act 
     (42 U.S.C. 1395w-4) is amended--
       (A) in subsection (b)--
       (i) in paragraph (4)(B), by inserting ``, and for 2010 and 
     2011, dual-energy x-ray absorptiometry services (as described 
     in paragraph (6))'' before the period at the end; and
       (ii) by adding at the end the following new paragraph:
       ``(6) Treatment of bone mass scans.--For dual-energy x-ray 
     absorptiometry services (identified in 2006 by HCPCS codes 
     76075 and 76077 (and any succeeding codes)) furnished during 
     2010 and 2011, instead of the payment amount that would 
     otherwise be determined under this section for such years, 
     the payment amount shall be equal to 70 percent of the 
     product of--
       ``(A) the relative value for the service (as determined in 
     subsection (c)(2)) for 2006;
       ``(B) the conversion factor (established under subsection 
     (d)) for 2006; and
       ``(C) the geographic adjustment factor (established under 
     subsection (e)(2)) for the service for the fee schedule area 
     for 2010 and 2011, respectively.''; and
       (B) in subsection (c)(2)(B)(iv)--
       (i) in subclause (II), by striking ``and'' at the end;
       (ii) in subclause (III), by striking the period at the end 
     and inserting ``; and''; and
       (iii) by adding at the end the following new subclause:

       ``(IV) subsection (b)(6) shall not be taken into account in 
     applying clause (ii)(II) for 2010 or 2011.''.

       (2) Implementation.--Notwithstanding any other provision of 
     law, the Secretary may implement the amendments made by 
     paragraph (1) by program instruction or otherwise.
       (b) Study and Report by the Institute of Medicine.--
       (1) In general.--The Secretary of Health and Human Services 
     is authorized to enter into an agreement with the Institute 
     of Medicine of the National Academies to conduct a study on 
     the ramifications of Medicare payment reductions for dual-
     energy x-ray absorptiometry (as described in section 
     1848(b)(6) of the Social Security Act, as added by subsection 
     (a)(1)) during 2007, 2008, and 2009 on beneficiary access to 
     bone mass density tests.
       (2) Report.--An agreement entered into under paragraph (1) 
     shall provide for the Institute of Medicine to submit to the 
     Secretary and to Congress a report containing the results of 
     the study conducted under such paragraph.

     SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND.

       Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 
     1395iii) is amended by striking ``$22,290,000,000'' and 
     inserting ``$0''.

     SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC LABORATORY 
                   TESTS.

       (a) Demonstration Project.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     conduct a demonstration project under part B title XVIII of 
     the Social Security Act under which separate payments are 
     made under such part for complex diagnostic laboratory tests 
     provided to individuals under such part. Under the 
     demonstration project, the Secretary shall establish 
     appropriate payment rates for such tests.
       (2) Covered complex diagnostic laboratory test defined.--In 
     this section, the term ``complex diagnostic laboratory test'' 
     means a diagnostic laboratory test--
       (A) that is an analysis of gene protein expression, 
     topographic genotyping, or a cancer chemotherapy sensitivity 
     assay;
       (B) that is determined by the Secretary to be a laboratory 
     test for which there is not an alternative test having 
     equivalent performance characteristics;
       (C) which is billed using a Health Care Procedure Coding 
     System (HCPCS) code other than a not otherwise classified 
     code under such Coding System;
       (D) which is approved or cleared by the Food and Drug 
     Administration or is covered under title XVIII of the Social 
     Security Act; and
       (E) is described in section 1861(s)(3) of the Social 
     Security Act (42 U.S.C. 1395x(s)(3)).
       (3) Separate payment defined.--In this section, the term 
     ``separate payment'' means direct payment to a laboratory 
     (including a hospital-based or independent laboratory) that 
     performs a complex diagnostic laboratory test with respect to 
     a specimen collected from an individual during a period in 
     which the individual is a patient of a hospital if the test 
     is performed after such period of hospitalization and if 
     separate payment would not otherwise be made under title 
     XVIII of the Social Security Act by reason of sections 
     1862(a)(14) and 1866(a)(1)(H)(i) of the such Act (42 U.S.C. 
     1395y(a)(14); 42 U.S.C. 1395cc(a)(1)(H)(i)).
       (b) Duration.--Subject to subsection (c)(2), the Secretary 
     shall conduct the demonstration project under this section 
     for the 2-year period beginning on July 1, 2011.
       (c) Payments and Limitation.--Payments under the 
     demonstration project under this section shall--
       (1) be made from the Federal Supplemental Medical Insurance 
     Trust Fund under section 1841 of the Social Security Act (42 
     U.S.C. 1395t); and
       (2) may not exceed $100,000,000.
       (d) Report.--Not later than 2 years after the completion of 
     the demonstration project under this section, the Secretary 
     shall submit to Congress a report on the project. Such report 
     shall include--
       (1) an assessment of the impact of the demonstration 
     project on access to care, quality of care, health outcomes, 
     and expenditures under title XVIII of the Social Security Act 
     (including any savings under such title); and
       (2) such recommendations as the Secretary determines 
     appropriate.
       (e) Implementation Funding.--For purposes of administering 
     this section (including preparing and submitting the report 
     under subsection (d)), the Secretary shall provide for the 
     transfer, from the Federal Supplemental Medical Insurance 
     Trust Fund under section 1841 of the Social Security Act (42 
     U.S.C. 1395t), to the Centers for Medicare & Medicaid 
     Services Program Management Account, of $5,000,000. Amounts 
     transferred under the preceding sentence shall remain 
     available until expended.

     SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE 
                   SERVICES.

       Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. 
     1395l(a)(1)(K)) is amended by inserting ``(or 100 percent for 
     services furnished on or after January 1, 2011)'' after 
     ``1992, 65 percent''.

                       PART II--RURAL PROTECTIONS

     SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

       (a) In General.--Section 1833(t)(7)(D)(i) of the Social 
     Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended--
       (1) in subclause (II)--
       (A) in the first sentence, by striking ``2010''and 
     inserting ``2011''; and

[[Page 4285]]

       (B) in the second sentence, by striking ``or 2009'' and 
     inserting ``, 2009, or 2010''; and
       (2) in subclause (III), by striking ``January 1, 2010'' and 
     inserting ``January 1, 2011''.
       (b) Permitting All Sole Community Hospitals To Be Eligible 
     for Hold Harmless.--Section 1833(t)(7)(D)(i)(III) of the 
     Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is 
     amended by adding at the end the following new sentence: ``In 
     the case of covered OPD services furnished on or after 
     January 1, 2010, and before January 1, 2011, the preceding 
     sentence shall be applied without regard to the 100-bed 
     limitation.''.

     SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS 
                   FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY 
                   TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN 
                   RURAL AREAS.

       Section 416(b) of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l-
     4), as amended by section 105 of division B of the Tax Relief 
     and Health Care Act of 2006 (42 U.S.C. 1395l note) and 
     section 107 of the Medicare, Medicaid, and SCHIP Extension 
     Act of 2007 (42 U.S.C. 1395l note), is amended by inserting 
     ``or during the 1-year period beginning on July 1, 2010'' 
     before the period at the end.

     SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL 
                   DEMONSTRATION PROGRAM.

       (a) One-year Extension.--Section 410A of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (Public Law 108-173; 117 Stat. 2272) is amended by adding at 
     the end the following new subsection:
       ``(g) One-Year Extension of Demonstration Program.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, the Secretary shall conduct the 
     demonstration program under this section for an additional 1-
     year period (in this section referred to as the `1-year 
     extension period') that begins on the date immediately 
     following the last day of the initial 5-year period under 
     subsection (a)(5).
       ``(2) Expansion of demonstration states.--Notwithstanding 
     subsection (a)(2), during the 1-year extension period, the 
     Secretary shall expand the number of States with low 
     population densities determined by the Secretary under such 
     subsection to 20. In determining which States to include in 
     such expansion, the Secretary shall use the same criteria and 
     data that the Secretary used to determine the States under 
     such subsection for purposes of the initial 5-year period.
       ``(3) Increase in maximum number of hospitals participating 
     in the demonstration program.--Notwithstanding subsection 
     (a)(4), during the 1-year extension period, not more than 30 
     rural community hospitals may participate in the 
     demonstration program under this section.
       ``(4) No affect on hospitals in demonstration program on 
     date of enactment.--In the case of a rural community hospital 
     that is participating in the demonstration program under this 
     section as of the last day of the initial 5-year period, the 
     Secretary shall provide for the continued participation of 
     such rural community hospital in the demonstration program 
     during the 1-year extension period unless the rural community 
     hospital makes an election, in such form and manner as the 
     Secretary may specify, to discontinue such participation.''.
       (b) Conforming Amendments.--Subsection (a)(5) of section 
     410A of the Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (Public Law 108-173; 117 Stat. 
     2272) is amended by inserting ``(in this section referred to 
     as the `initial 5-year period') and, as provided in 
     subsection (g), for the 1-year extension period'' after ``5-
     year period''.
       (c) Technical Amendments.--
       (1) Subsection (b) of section 410A of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (Public Law 108-173; 117 Stat. 2272) is amended--
       (A) in paragraph (1)(B)(ii), by striking ``2)'' and 
     inserting ``2))''; and
       (B) in paragraph (2), by inserting ``cost'' before 
     ``reporting period'' the first place such term appears in 
     each of subparagraphs (A) and (B).
       (2) Subsection (f)(1) of section 410A of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (Public Law 108-173; 117 Stat. 2272) is amended--
       (A) in subparagraph (A)(ii), by striking ``paragraph (2)'' 
     and inserting ``subparagraph (B)''; and
       (B) in subparagraph (B), by striking ``paragraph (1)(B)'' 
     and inserting ``subparagraph (A)(ii)''.

     SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) 
                   PROGRAM.

       (a) Extension of Payment Methodology.--Section 
     1886(d)(5)(G) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(G)) is amended--
       (1) in clause (i), by striking ``October 1, 2011'' and 
     inserting ``October 1, 2012''; and
       (2) in clause (ii)(II), by striking ``October 1, 2011'' and 
     inserting ``October 1, 2012''.
       (b) Conforming Amendments.--
       (1) Extension of target amount.--Section 1886(b)(3)(D) of 
     the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is 
     amended--
       (A) in the matter preceding clause (i), by striking 
     ``October 1, 2011'' and inserting ``October 1, 2012''; and
       (B) in clause (iv), by striking ``through fiscal year 
     2011'' and inserting ``through fiscal year 2012''.
       (2) Permitting hospitals to decline reclassification.--
     Section 13501(e)(2) of the Omnibus Budget Reconciliation Act 
     of 1993 (42 U.S.C. 1395ww note) is amended by striking 
     ``through fiscal year 2011'' and inserting ``through fiscal 
     year 2012''.

     SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT 
                   HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME 
                   HOSPITALS.

       Section 1886(d)(12) of the Social Security Act (42 U.S.C. 
     1395ww(d)(12)) is amended--
       (1) in subparagraph (A), by inserting ``or (D)'' after 
     ``subparagraph (B)'';
       (2) in subparagraph (B), in the matter preceding clause 
     (i), by striking ``The Secretary'' and inserting ``For 
     discharges occurring in fiscal years 2005 through 2010 and 
     for discharges occurring in fiscal year 2013 and subsequent 
     fiscal years, the Secretary'';
       (3) in subparagraph (C)(i)--
       (A) by inserting ``(or, with respect to fiscal years 2011 
     and 2012, 15 road miles)'' after ``25 road miles''; and
       (B) by inserting ``(or, with respect to fiscal years 2011 
     and 2012, 1,500 discharges of individuals entitled to, or 
     enrolled for, benefits under part A)'' after ``800 
     discharges''; and
       (4) by adding at the end the following new subparagraph:
       ``(D) Temporary applicable percentage increase.--For 
     discharges occurring in fiscal years 2011 and 2012, the 
     Secretary shall determine an applicable percentage increase 
     for purposes of subparagraph (A) using a continuous linear 
     sliding scale ranging from 25 percent for low-volume 
     hospitals with 200 or fewer discharges of individuals 
     entitled to, or enrolled for, benefits under part A in the 
     fiscal year to 0 percent for low-volume hospitals with 
     greater than 1,500 discharges of such individuals in the 
     fiscal year.''.

     SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON 
                   COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN 
                   RURAL COUNTIES.

       (a) Removal of Limitation on Number of Eligible Counties 
     Selected.--Subsection (d)(3) of section 123 of the Medicare 
     Improvements for Patients and Providers Act of 2008 (42 
     U.S.C. 1395i-4 note) is amended by striking ``not more than 
     6''.
       (b) Removal of References to Rural Health Clinic Services 
     and Inclusion of Physicians' Services in Scope of 
     Demonstration Project.--Such section 123 is amended--
       (1) in subsection (d)(4)(B)(i)(3), by striking subclause 
     (III); and
       (2) in subsection (j)--
       (A) in paragraph (8), by striking subparagraph (B) and 
     inserting the following:
       ``(B) Physicians' services (as defined in section 1861(q) 
     of the Social Security Act (42 U.S.C. 1395x(q)).'';
       (B) by striking paragraph (9); and
       (C) by redesignating paragraph (10) as paragraph (9).

     SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR 
                   HEALTH CARE PROVIDERS SERVING IN RURAL AREAS.

       (a) Study.--The Medicare Payment Advisory Commission shall 
     conduct a study on the adequacy of payments for items and 
     services furnished by providers of services and suppliers in 
     rural areas under the Medicare program under title XVIII of 
     the Social Security Act (42 U.S.C. 1395 et seq.). Such study 
     shall include an analysis of--
       (1) any adjustments in payments to providers of services 
     and suppliers that furnish items and services in rural areas;
       (2) access by Medicare beneficiaries to items and services 
     in rural areas;
       (3) the adequacy of payments to providers of services and 
     suppliers that furnish items and services in rural areas; and
       (4) the quality of care furnished in rural areas.
       (b) Report.--Not later than January 1, 2011, the Medicare 
     Payment Advisory Commission shall submit to Congress a report 
     containing the results of the study conducted under 
     subsection (a). Such report shall include recommendations on 
     appropriate modifications to any adjustments in payments to 
     providers of services and suppliers that furnish items and 
     services in rural areas, together with recommendations for 
     such legislation and administrative action as the Medicare 
     Payment Advisory Commission determines appropriate.

     SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS 
                   HOSPITAL SERVICES.

       (a) In General.--Subsections (g)(2)(A) and (l)(8) of 
     section 1834 of the Social Security Act (42 U.S.C. 1395m) are 
     each amended by inserting ``101 percent of'' before ``the 
     reasonable costs''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect as if included in the enactment of section 
     405(a) of the Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (Public Law 108-173; 117 Stat. 
     2266).

     SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL 
                   HOSPITAL FLEXIBILITY PROGRAM.

       (a) Authorization.--Section 1820(j) of the Social Security 
     Act (42 U.S.C. 1395i-4(j)) is amended--
       (1) by striking ``2010, and for'' and inserting ``2010, 
     for''; and
       (2) by inserting ``and for making grants to all States 
     under subsection (g), such sums as may be necessary in each 
     of fiscal years 2011 and 2012, to remain available until 
     expended'' before the period at the end.

[[Page 4286]]

       (b) Use of Funds.--Section 1820(g)(3) of the Social 
     Security Act (42 U.S.C. 1395i-4(g)(3)) is amended--
       (1) in subparagraph (A), by inserting ``and to assist such 
     hospitals in participating in delivery system reforms under 
     the provisions of and amendments made by the Patient 
     Protection and Affordable Care Act, such as value-based 
     purchasing programs, accountable care organizations under 
     section 1899, the National pilot program on payment bundling 
     under section 1866D, and other delivery system reform 
     programs determined appropriate by the Secretary'' before the 
     period at the end; and
       (2) in subparagraph (E)--
       (A) by striking ``, and to offset'' and inserting ``, to 
     offset''; and
       (B) by inserting ``and to participate in delivery system 
     reforms under the provisions of and amendments made by the 
     Patient Protection and Affordable Care Act, such as value-
     based purchasing programs, accountable care organizations 
     under section 1899, the National pilot program on payment 
     bundling under section 1866D, and other delivery system 
     reform programs determined appropriate by the Secretary'' 
     before the period at the end.
       (c) Effective Date.--The amendments made by this section 
     shall apply to grants made on or after January 1, 2010.

                  PART III--IMPROVING PAYMENT ACCURACY

     SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.

       (a) Rebasing Home Health Prospective Payment Amount.--
       (1) In general.--Section 1895(b)(3)(A) of the Social 
     Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended--
       (A) in clause (i)(III), by striking ``For periods'' and 
     inserting ``Subject to clause (iii), for periods''; and
       (B) by adding at the end the following new clause:
       ``(iii) Adjustment for 2013 and subsequent years.--

       ``(I) In general.--Subject to subclause (II), for 2013 and 
     subsequent years, the amount (or amounts) that would 
     otherwise be applicable under clause (i)(III) shall be 
     adjusted by a percentage determined appropriate by the 
     Secretary to reflect such factors as changes in the number of 
     visits in an episode, the mix of services in an episode, the 
     level of intensity of services in an episode, the average 
     cost of providing care per episode, and other factors that 
     the Secretary considers to be relevant. In conducting the 
     analysis under the preceding sentence, the Secretary may 
     consider differences between hospital-based and freestanding 
     agencies, between for-profit and nonprofit agencies, and 
     between the resource costs of urban and rural agencies. Such 
     adjustment shall be made before the update under subparagraph 
     (B) is applied for the year.
       ``(II) Transition.--The Secretary shall provide for a 4-
     year phase-in (in equal increments) of the adjustment under 
     subclause (I), with such adjustment being fully implemented 
     for 2016. During each year of such phase-in, the amount of 
     any adjustment under subclause (I) for the year may not 
     exceed 3.5 percent of the amount (or amounts) applicable 
     under clause (i)(III) as of the date of enactment of the 
     Patient Protection and Affordable Care Act.''.

       (2) MedPAC study and report.--
       (A) Study.--The Medicare Payment Advisory Commission shall 
     conduct a study on the implementation of the amendments made 
     by paragraph (1). Such study shall include an analysis of the 
     impact of such amendments on--
       (i) access to care;
       (ii) quality outcomes;
       (iii) the number of home health agencies; and
       (iv) rural agencies, urban agencies, for-profit agencies, 
     and nonprofit agencies.
       (B) Report.--Not later than January 1, 2015, the Medicare 
     Payment Advisory Commission shall submit to Congress a report 
     on the study conducted under subparagraph (A), together with 
     recommendations for such legislation and administrative 
     action as the Commission determines appropriate.
       (b) Program-specific Outlier Cap.--Section 1895(b) of the 
     Social Security Act (42 U.S.C. 1395fff(b)) is amended--
       (1) in paragraph (3)(C), by striking ``the aggregate'' and 
     all that follows through the period at the end and inserting 
     ``5 percent of the total payments estimated to be made based 
     on the prospective payment system under this subsection for 
     the period.''; and
       (2) in paragraph (5)--
       (A) by striking ``Outliers.--The Secretary'' and inserting 
     the following: ``Outliers.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary'';
       (B) in subparagraph (A), as added by subparagraph (A), by 
     striking ``5 percent'' and inserting ``2.5 percent''; and
       (C) by adding at the end the following new subparagraph:
       ``(B) Program specific outlier cap.--The estimated total 
     amount of additional payments or payment adjustments made 
     under subparagraph (A) with respect to a home health agency 
     for a year (beginning with 2011) may not exceed an amount 
     equal to 10 percent of the estimated total amount of payments 
     made under this section (without regard to this paragraph) 
     with respect to the home health agency for the year.''.
       (c) Application of the Medicare Rural Home Health Add-on 
     Policy.--Section 421 of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173; 117 Stat. 2283), as amended by section 5201(b) of the 
     Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat. 
     46), is amended--
       (1) in the section heading, by striking ``ONE-YEAR'' and 
     inserting ``TEMPORARY''; and
       (2) in subsection (a)--
       (A) by striking ``, and episodes'' and inserting ``, 
     episodes'';
       (B) by inserting ``and episodes and visits ending on or 
     after April 1, 2010, and before January 1, 2016,'' after 
     ``January 1, 2007,''; and
       (C) by inserting ``(or, in the case of episodes and visits 
     ending on or after April 1, 2010, and before January 1, 2016, 
     3 percent)'' before the period at the end.
       (d) Study and Report on the Development of Home Health 
     Payment Reforms in Order To Ensure Access to Care and Quality 
     Services.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     conduct a study to evaluate the costs and quality of care 
     among efficient home health agencies relative to other such 
     agencies in providing ongoing access to care and in treating 
     Medicare beneficiaries with varying severity levels of 
     illness. Such study shall include an analysis of the 
     following:
       (A) Methods to revise the home health prospective payment 
     system under section 1895 of the Social Security Act (42 
     U.S.C. 1395fff) to more accurately account for the costs 
     related to patient severity of illness or to improving 
     beneficiary access to care, including--
       (i) payment adjustments for services that may be under- or 
     over-valued;
       (ii) necessary changes to reflect the resource use relative 
     to providing home health services to low-income Medicare 
     beneficiaries or Medicare beneficiaries living in medically 
     underserved areas;
       (iii) ways the outlier payment may be improved to more 
     accurately reflect the cost of treating Medicare 
     beneficiaries with high severity levels of illness;
       (iv) the role of quality of care incentives and penalties 
     in driving provider and patient behavior;
       (v) improvements in the application of a wage index; and
       (vi) other areas determined appropriate by the Secretary.
       (B) The validity and reliability of responses on the OASIS 
     instrument with particular emphasis on questions that relate 
     to higher payment under the home health prospective payment 
     system and higher outcome scores under Home Care Compare.
       (C) Additional research or payment revisions under the home 
     health prospective payment system that may be necessary to 
     set the payment rates for home health services based on costs 
     of high-quality and efficient home health agencies or to 
     improve Medicare beneficiary access to care.
       (D) A timetable for implementation of any appropriate 
     changes based on the analysis of the matters described in 
     subparagraphs (A), (B), and (C).
       (E) Other areas determined appropriate by the Secretary.
       (2) Considerations.--In conducting the study under 
     paragraph (1), the Secretary shall consider whether certain 
     factors should be used to measure patient severity of illness 
     and access to care, such as--
       (A) population density and relative patient access to care;
       (B) variations in service costs for providing care to 
     individuals who are dually eligible under the Medicare and 
     Medicaid programs;
       (C) the presence of severe or chronic diseases, as 
     evidenced by multiple, discontinuous home health episodes;
       (D) poverty status, as evidenced by the receipt of 
     Supplemental Security Income under title XVI of the Social 
     Security Act;
       (E) the absence of caregivers;
       (F) language barriers;
       (G) atypical transportation costs;
       (H) security costs; and
       (I) other factors determined appropriate by the Secretary.
       (3) Report.--Not later than March 1, 2011, the Secretary 
     shall submit to Congress a report on the study conducted 
     under paragraph (1), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.
       (4) Consultations.--In conducting the study under paragraph 
     (1) and preparing the report under paragraph (3), the 
     Secretary shall consult with--
       (A) stakeholders representing home health agencies;
       (B) groups representing Medicare beneficiaries;
       (C) the Medicare Payment Advisory Commission;
       (D) the Inspector General of the Department of Health and 
     Human Services; and
       (E) the Comptroller General of the United States.

     SEC. 3132. HOSPICE REFORM.

       (a) Hospice Care Payment Reforms.--
       (1) In general.--Section 1814(i) of the Social Security Act 
     (42 U.S.C. 1395f(i)), as amended by section 3004(c), is 
     amended--
       (A) by redesignating paragraph (6) as paragraph (7); and
       (B) by inserting after paragraph (5) the following new 
     paragraph:
       ``(6)(A) The Secretary shall collect additional data and 
     information as the Secretary determines appropriate to revise 
     payments for hospice care under this subsection pursuant to 
     subparagraph (D) and for other purposes as determined 
     appropriate by the Secretary. The Secretary shall begin to 
     collect such data by not later than January 1, 2011.

[[Page 4287]]

       ``(B) The additional data and information to be collected 
     under subparagraph (A) may include data and information on--
       ``(i) charges and payments;
       ``(ii) the number of days of hospice care which are 
     attributable to individuals who are entitled to, or enrolled 
     for, benefits under part A; and
       ``(iii) with respect to each type of service included in 
     hospice care--
       ``(I) the number of days of hospice care attributable to 
     the type of service;
       ``(II) the cost of the type of service; and
       ``(III) the amount of payment for the type of service;
       ``(iv) charitable contributions and other revenue of the 
     hospice program;
       ``(v) the number of hospice visits;
       ``(vi) the type of practitioner providing the visit; and
       ``(vii) the length of the visit and other basic information 
     with respect to the visit.
       ``(C) The Secretary may collect the additional data and 
     information under subparagraph (A) on cost reports, claims, 
     or other mechanisms as the Secretary determines to be 
     appropriate.
       ``(D)(i) Notwithstanding the preceding paragraphs of this 
     subsection, not earlier than October 1, 2013, the Secretary 
     shall, by regulation, implement revisions to the methodology 
     for determining the payment rates for routine home care and 
     other services included in hospice care under this part, as 
     the Secretary determines to be appropriate. Such revisions 
     may be based on an analysis of data and information collected 
     under subparagraph (A). Such revisions may include 
     adjustments to per diem payments that reflect changes in 
     resource intensity in providing such care and services during 
     the course of the entire episode of hospice care.
       ``(ii) Revisions in payment implemented pursuant to clause 
     (i) shall result in the same estimated amount of aggregate 
     expenditures under this title for hospice care furnished in 
     the fiscal year in which such revisions in payment are 
     implemented as would have been made under this title for such 
     care in such fiscal year if such revisions had not been 
     implemented.
       ``(E) The Secretary shall consult with hospice programs and 
     the Medicare Payment Advisory Commission regarding the 
     additional data and information to be collected under 
     subparagraph (A) and the payment revisions under subparagraph 
     (D).''.
       (2) Conforming amendments.--Section 1814(i)(1)(C) of the 
     Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended--
       (A) in clause (ii)--
       (i) in the matter preceding subclause (I), by inserting 
     ``(before the first fiscal year in which the payment 
     revisions described in paragraph (6)(D) are implemented)'' 
     after ``subsequent fiscal year''; and
       (ii) in subclause (VII), by inserting ``(before the first 
     fiscal year in which the payment revisions described in 
     paragraph (6)(D) are implemented), subject to clause (iv),'' 
     after ``subsequent fiscal year''; and
       (B) by adding at the end the following new clause:
       ``(iii) With respect to routine home care and other 
     services included in hospice care furnished during fiscal 
     years subsequent to the first fiscal year in which payment 
     revisions described in paragraph (6)(D) are implemented, the 
     payment rates for such care and services shall be the payment 
     rates in effect under this clause during the preceding fiscal 
     year increased by, subject to clause (iv), the market basket 
     percentage increase (as defined in section 
     1886(b)(3)(B)(iii)) for the fiscal year.''.
       (b) Adoption of MedPAC Hospice Program Eligibility 
     Recertification Recommendations.--Section 1814(a)(7) of the 
     Social Security Act (42 U.S.C. 1395f(a)(7)) is amended--
       (1) in subparagraph (B), by striking ``and'' at the end; 
     and
       (2) by adding at the end the following new subparagraph:
       ``(D) on and after January 1, 2011--
       ``(i) a hospice physician or nurse practitioner has a face-
     to-face encounter with the individual to determine continued 
     eligibility of the individual for hospice care prior to the 
     180th-day recertification and each subsequent recertification 
     under subparagraph (A)(ii) and attests that such visit took 
     place (in accordance with procedures established by the 
     Secretary); and
       ``(ii) in the case of hospice care provided an individual 
     for more than 180 days by a hospice program for which the 
     number of such cases for such program comprises more than a 
     percent (specified by the Secretary) of the total number of 
     such cases for all programs under this title, the hospice 
     care provided to such individual is medically reviewed (in 
     accordance with procedures established by the Secretary); 
     and''.

     SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE 
                   HOSPITAL (DSH) PAYMENTS.

       Section 1886 of the Social Security Act (42 U.S.C. 1395ww), 
     as amended by sections 3001, 3008, and 3025, is amended--
       (1) in subsection (d)(5)(F)(i), by striking ``For'' and 
     inserting ``Subject to subsection (r), for''; and
       (2) by adding at the end the following new subsection:
       ``(r) Adjustments to Medicare DSH Payments.--
       ``(1) Empirically justified dsh payments.--For fiscal year 
     2015 and each subsequent fiscal year, instead of the amount 
     of disproportionate share hospital payment that would 
     otherwise be made under subsection (d)(5)(F) to a subsection 
     (d) hospital for the fiscal year, the Secretary shall pay to 
     the subsection (d) hospital 25 percent of such amount (which 
     represents the empirically justified amount for such payment, 
     as determined by the Medicare Payment Advisory Commission in 
     its March 2007 Report to the Congress).
       ``(2) Additional payment.--In addition to the payment made 
     to a subsection (d) hospital under paragraph (1), for fiscal 
     year 2015 and each subsequent fiscal year, the Secretary 
     shall pay to such subsection (d) hospitals an additional 
     amount equal to the product of the following factors:
       ``(A) Factor one.--A factor equal to the difference 
     between--
       ``(i) the aggregate amount of payments that would be made 
     to subsection (d) hospitals under subsection (d)(5)(F) if 
     this subsection did not apply for such fiscal year (as 
     estimated by the Secretary); and
       ``(ii) the aggregate amount of payments that are made to 
     subsection (d) hospitals under paragraph (1) for such fiscal 
     year (as so estimated).
       ``(B) Factor two.--
       ``(i) Fiscal years 2015, 2016, and 2017.--For each of 
     fiscal years 2015, 2016, and 2017, a factor equal to 1 minus 
     the percent change (divided by 100) in the percent of 
     individuals under the age of 65 who are uninsured, as 
     determined by comparing the percent of such individuals--

       ``(I) who are uninsured in 2012, the last year before 
     coverage expansion under the Patient Protection and 
     Affordable Care Act (as calculated by the Secretary based on 
     the most recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     such Act that, if determined in the affirmative, would clear 
     such Act for enrollment); and
       ``(II) who are uninsured in the most recent period for 
     which data is available (as so calculated).

       ``(ii) 2018 and subsequent years.--For fiscal year 2018 and 
     each subsequent fiscal year, a factor equal to 1 minus the 
     percent change (divided by 100) in the percent of individuals 
     who are uninsured, as determined by comparing the percent of 
     individuals--

       ``(I) who are uninsured in 2012 (as estimated by the 
     Secretary, based on data from the Census Bureau or other 
     sources the Secretary determines appropriate, and certified 
     by the Chief Actuary of the Centers for Medicare & Medicaid 
     Services); and
       ``(II) who are uninsured in the most recent period for 
     which data is available (as so estimated and certified).

       ``(C) Factor three.--A factor equal to the percent, for 
     each subsection (d) hospital, that represents the quotient 
     of--
       ``(i) the amount of uncompensated care for such hospital 
     for a period selected by the Secretary (as estimated by the 
     Secretary, based on appropriate data (including, in the case 
     where the Secretary determines that alternative data is 
     available which is a better proxy for the costs of subsection 
     (d) hospitals for treating the uninsured, the use of such 
     alternative data)); and
       ``(ii) the aggregate amount of uncompensated care for all 
     subsection (d) hospitals that receive a payment under this 
     subsection for such period (as so estimated, based on such 
     data).
       ``(3) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the following:
       ``(A) Any estimate of the Secretary for purposes of 
     determining the factors described in paragraph (2).
       ``(B) Any period selected by the Secretary for such 
     purposes.''.

     SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

       (a) In General.--Section 1848(c)(2) of the Social Security 
     Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end 
     the following new subparagraphs:
       ``(K) Potentially misvalued codes.--
       ``(i) In general.--The Secretary shall--

       ``(I) periodically identify services as being potentially 
     misvalued using criteria specified in clause (ii); and
       ``(II) review and make appropriate adjustments to the 
     relative values established under this paragraph for services 
     identified as being potentially misvalued under subclause 
     (I).

       ``(ii) Identification of potentially misvalued codes.--For 
     purposes of identifying potentially misvalued services 
     pursuant to clause (i)(I), the Secretary shall examine (as 
     the Secretary determines to be appropriate) codes (and 
     families of codes as appropriate) for which there has been 
     the fastest growth; codes (and families of codes as 
     appropriate) that have experienced substantial changes in 
     practice expenses; codes for new technologies or services 
     within an appropriate period (such as 3 years) after the 
     relative values are initially established for such codes; 
     multiple codes that are frequently billed in conjunction with 
     furnishing a single service; codes with low relative values, 
     particularly those that are often billed multiple times for a 
     single treatment; codes which have not been subject to review 
     since the implementation of the RBRVS (the so-called 
     `Harvard-valued codes'); and such other codes determined to 
     be appropriate by the Secretary.
       ``(iii) Review and adjustments.--

       ``(I) The Secretary may use existing processes to receive 
     recommendations on the review and appropriate adjustment of 
     potentially misvalued services described in clause (i)(II).

       ``(II) The Secretary may conduct surveys, other data 
     collection activities, studies, or other analyses as the 
     Secretary determines to be appropriate to facilitate the 
     review and appropriate adjustment described in clause 
     (i)(II).

[[Page 4288]]

       ``(III) The Secretary may use analytic contractors to 
     identify and analyze services identified under clause (i)(I), 
     conduct surveys or collect data, and make recommendations on 
     the review and appropriate adjustment of services described 
     in clause (i)(II).
       ``(IV) The Secretary may coordinate the review and 
     appropriate adjustment described in clause (i)(II) with the 
     periodic review described in subparagraph (B).
       ``(V) As part of the review and adjustment described in 
     clause (i)(II), including with respect to codes with low 
     relative values described in clause (ii), the Secretary may 
     make appropriate coding revisions (including using existing 
     processes for consideration of coding changes) which may 
     include consolidation of individual services into bundled 
     codes for payment under the fee schedule under subsection 
     (b).
       ``(VI) The provisions of subparagraph (B)(ii)(II) shall 
     apply to adjustments to relative value units made pursuant to 
     this subparagraph in the same manner as such provisions apply 
     to adjustments under subparagraph (B)(ii)(II).

       ``(L) Validating relative value units.--
       ``(i) In general.--The Secretary shall establish a process 
     to validate relative value units under the fee schedule under 
     subsection (b).
       ``(ii) Components and elements of work.--The process 
     described in clause (i) may include validation of work 
     elements (such as time, mental effort and professional 
     judgment, technical skill and physical effort, and stress due 
     to risk) involved with furnishing a service and may include 
     validation of the pre-, post-, and intra-service components 
     of work.
       ``(iii) Scope of codes.--The validation of work relative 
     value units shall include a sampling of codes for services 
     that is the same as the codes listed under subparagraph 
     (K)(ii).
       ``(iv) Methods.--The Secretary may conduct the validation 
     under this subparagraph using methods described in subclauses 
     (I) through (V) of subparagraph (K)(iii) as the Secretary 
     determines to be appropriate.
       ``(v) Adjustments.--The Secretary shall make appropriate 
     adjustments to the work relative value units under the fee 
     schedule under subsection (b). The provisions of subparagraph 
     (B)(ii)(II) shall apply to adjustments to relative value 
     units made pursuant to this subparagraph in the same manner 
     as such provisions apply to adjustments under subparagraph 
     (B)(ii)(II).''.
       (b) Implementation.--
       (1) Administration.--
       (A) Chapter 35 of title 44, United States Code and the 
     provisions of the Federal Advisory Committee Act (5 U.S.C. 
     App.) shall not apply to this section or the amendment made 
     by this section.
       (B) Notwithstanding any other provision of law, the 
     Secretary may implement subparagraphs (K) and (L) of 
     1848(c)(2) of the Social Security Act, as added by subsection 
     (a), by program instruction or otherwise.
       (C) Section 4505(d) of the Balanced Budget Act of 1997 is 
     repealed.
       (D) Except for provisions related to confidentiality of 
     information, the provisions of the Federal Acquisition 
     Regulation shall not apply to this section or the amendment 
     made by this section.
       (2) Focusing cms resources on potentially overvalued 
     codes.--Section 1868(a) of the Social Security Act (42 U.S.C. 
     1395ee(a)) is repealed.

     SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR 
                   ADVANCED IMAGING SERVICES.

       (a) Adjustment in Practice Expense To Reflect Higher 
     Presumed Utilization.--Section 1848 of the Social Security 
     Act (42 U.S.C. 1395w-4) is amended--
       (1) in subsection (b)(4)--
       (A) in subparagraph (B), by striking ``subparagraph (A)'' 
     and inserting ``this paragraph''; and
       (B) by adding at the end the following new subparagraph:
       ``(C) Adjustment in practice expense to reflect higher 
     presumed utilization.--Consistent with the methodology for 
     computing the number of practice expense relative value units 
     under subsection (c)(2)(C)(ii) with respect to advanced 
     diagnostic imaging services (as defined in section 
     1834(e)(1)(B)) furnished on or after January 1, 2010, the 
     Secretary shall adjust such number of units so it reflects--
       ``(i) in the case of services furnished on or after January 
     1, 2010, and before January 1, 2013, a 65 percent (rather 
     than 50 percent) presumed rate of utilization of imaging 
     equipment;
       ``(ii) in the case of services furnished on or after 
     January 1, 2013, and before January 1, 2014, a 70 percent 
     (rather than 50 percent) presumed rate of utilization of 
     imaging equipment; and
       ``(iii) in the case of services furnished on or after 
     January 1, 2014, a 75 percent (rather than 50 percent) 
     presumed rate of utilization of imaging equipment.''; and
       (2) in subsection (c)(2)(B)(v), by adding at the end the 
     following new subclauses:

       ``(III) Change in presumed utilization level of certain 
     advanced diagnostic imaging services for 2010 through 2012.--
     Effective for fee schedules established beginning with 2010 
     and ending with 2012, reduced expenditures attributable to 
     the presumed rate of utilization of imaging equipment of 65 
     percent under subsection (b)(4)(C)(i) instead of a presumed 
     rate of utilization of such equipment of 50 percent.
       ``(IV) Change in presumed utilization level of certain 
     advanced diagnostic imaging services for 2013.--Effective for 
     fee schedules established for 2013, reduced expenditures 
     attributable to the presumed rate of utilization of imaging 
     equipment of 70 percent under subsection (b)(4)(C)(ii) 
     instead of a presumed rate of utilization of such equipment 
     of 50 percent.
       ``(V) Change in presumed utilization level of certain 
     advanced diagnostic imaging services for 2014 and subsequent 
     years.--Effective for fee schedules established beginning 
     with 2014, reduced expenditures attributable to the presumed 
     rate of utilization of imaging equipment of 75 percent under 
     subsection (b)(4)(C)(iii) instead of a presumed rate of 
     utilization of such equipment of 50 percent.''.

       (b) Adjustment in Technical Component ``discount'' on 
     Single-session Imaging to Consecutive Body Parts.--Section 
     1848 of the Social Security Act (42 U.S.C. 1395w-4), as 
     amended by subsection (a), is amended--
       (1) in subsection (b)(4), by adding at the end the 
     following new subparagraph:
       ``(D) Adjustment in technical component discount on single-
     session imaging involving consecutive body parts.--For 
     services furnished on or after July 1, 2010, the Secretary 
     shall increase the reduction in payments attributable to the 
     multiple procedure payment reduction applicable to the 
     technical component for imaging under the final rule 
     published by the Secretary in the Federal Register on 
     November 21, 2005 (part 405 of title 42, Code of Federal 
     Regulations) from 25 percent to 50 percent.''; and
       (2) in subsection (c)(2)(B)(v), by adding at the end the 
     following new subclause:

       ``(VI) Additional reduced payment for multiple imaging 
     procedures.--Effective for fee schedules established 
     beginning with 2010 (but not applied for services furnished 
     prior to July 1, 2010), reduced expenditures attributable to 
     the increase in the multiple procedure payment reduction from 
     25 to 50 percent (as described in subsection (b)(4)(D)).''.

       (c) Analysis by the Chief Actuary of the Centers for 
     Medicare & Medicaid Services.--Not later than January 1, 
     2013, the Chief Actuary of the Centers for Medicare & 
     Medicaid Services shall make publicly available an analysis 
     of whether, for the period of 2010 through 2019, the 
     cumulative expenditure reductions under title XVIII of the 
     Social Security Act that are attributable to the adjustments 
     under the amendments made by this section are projected to 
     exceed $3,000,000,000.

     SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS.

       (a) In General.--Section 1834(a)(7)(A) of the Social 
     Security Act (42 U.S.C. 1395m(a)(7)(A)) is amended--
       (1) in clause (i)--
       (A) in subclause (II), by inserting ``subclause (III) and'' 
     after ``Subject to''; and
       (B) by adding at the end the following new subclause:

       ``(III) Special rule for power-driven wheelchairs.--For 
     purposes of payment for power-driven wheelchairs, subclause 
     (II) shall be applied by substituting `15 percent' and `6 
     percent' for `10 percent' and `7.5 percent', respectively.''; 
     and

       (2) in clause (iii)--
       (A) in the heading, by inserting ``complex, 
     rehabilitative'' before ``power-driven''; and
       (B) by inserting ``complex, rehabilitative'' before 
     ``power-driven''.
       (b) Technical Amendment.--Section 1834(a)(7)(C)(ii)(II) of 
     the Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is 
     amended by striking ``(A)(ii) or''.
       (c) Effective Date.--
       (1) In general.--Subject to paragraph (2), the amendments 
     made by subsection (a) shall take effect on January 1, 2011, 
     and shall apply to power-driven wheelchairs furnished on or 
     after such date.
       (2) Application to competitive bidding.--The amendments 
     made by subsection (a) shall not apply to payment made for 
     items and services furnished pursuant to contracts entered 
     into under section 1847 of the Social Security Act (42 U.S.C. 
     1395w-3) prior to January 1, 2011, pursuant to the 
     implementation of subsection (a)(1)(B)(i)(I) of such section 
     1847.

     SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT.

       (a) Extension of Section 508 Hospital Reclassifications.--
       (1) In general.--Subsection (a) of section 106 of division 
     B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
     1395 note), as amended by section 117 of the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
     173) and section 124 of the Medicare Improvements for 
     Patients and Providers Act of 2008 (Public Law 110-275), is 
     amended by striking ``September 30, 2009'' and inserting 
     ``September 30, 2010''.
       (2) Use of particular wage index in fiscal year 2010.--For 
     purposes of implementation of the amendment made by this 
     subsection during fiscal year 2010, the Secretary shall use 
     the hospital wage index that was promulgated by the Secretary 
     in the Federal Register on August 27, 2009 (74 Fed. Reg. 
     43754), and any subsequent corrections.
       (b) Plan for Reforming the Medicare Hospital Wage Index 
     System.--
       (1) In general.--Not later than December 31, 2011, the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall submit to Congress a 
     report that includes a plan to reform the hospital wage index 
     system under section 1886 of the Social Security Act.
       (2) Details.--In developing the plan under paragraph (1), 
     the Secretary shall take into account the goals for reforming 
     such system set

[[Page 4289]]

     forth in the Medicare Payment Advisory Commission June 2007 
     report entitled ``Report to Congress: Promoting Greater 
     Efficiency in Medicare'', including establishing a new 
     hospital compensation index system that--
       (A) uses Bureau of Labor Statistics data, or other data or 
     methodologies, to calculate relative wages for each 
     geographic area involved;
       (B) minimizes wage index adjustments between and within 
     metropolitan statistical areas and statewide rural areas;
       (C) includes methods to minimize the volatility of wage 
     index adjustments that result from implementation of policy, 
     while maintaining budget neutrality in applying such 
     adjustments;
       (D) takes into account the effect that implementation of 
     the system would have on health care providers and on each 
     region of the country;
       (E) addresses issues related to occupational mix, such as 
     staffing practices and ratios, and any evidence on the effect 
     on quality of care or patient safety as a result of the 
     implementation of the system; and
       (F) provides for a transition.
       (3) Consultation.--In developing the plan under paragraph 
     (1), the Secretary shall consult with relevant affected 
     parties.
       (c) Use of Particular Criteria for Determining 
     Reclassifications.--Notwithstanding any other provision of 
     law, in making decisions on applications for reclassification 
     of a subsection (d) hospital (as defined in paragraph (1)(B) 
     of section 1886(d) of the Social Security Act (42 U.S.C. 
     1395ww(d)) for the purposes described in paragraph (10)(D)(v) 
     of such section for fiscal year 2011 and each subsequent 
     fiscal year (until the first fiscal year beginning on or 
     after the date that is 1 year after the Secretary of Health 
     and Human Services submits the report to Congress under 
     subsection (b)), the Geographic Classification Review Board 
     established under paragraph (10) of such section shall use 
     the average hourly wage comparison criteria used in making 
     such decisions as of September 30, 2008. The preceding 
     sentence shall be effected in a budget neutral manner.

     SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS.

       Section 1833(t) of the Social Security Act (42 U.S.C. 
     1395l(t)) is amended by adding at the end the following new 
     paragraph:
       ``(18) Authorization of adjustment for cancer hospitals.--
       ``(A) Study.--The Secretary shall conduct a study to 
     determine if, under the system under this subsection, costs 
     incurred by hospitals described in section 1886(d)(1)(B)(v) 
     with respect to ambulatory payment classification groups 
     exceed those costs incurred by other hospitals furnishing 
     services under this subsection (as determined appropriate by 
     the Secretary). In conducting the study under this 
     subparagraph, the Secretary shall take into consideration the 
     cost of drugs and biologicals incurred by such hospitals.
       ``(B) Authorization of adjustment.--Insofar as the 
     Secretary determines under subparagraph (A) that costs 
     incurred by hospitals described in section 1886(d)(1)(B)(v) 
     exceed those costs incurred by other hospitals furnishing 
     services under this subsection, the Secretary shall provide 
     for an appropriate adjustment under paragraph (2)(E) to 
     reflect those higher costs effective for services furnished 
     on or after January 1, 2011.''.

     SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.

       (a) In General.--Section 1847A of the Social Security Act 
     (42 U.S.C. 1395w-3a) is amended--
       (1) in subsection (b)--
       (A) in paragraph (1)--
       (i) in subparagraph (A), by striking ``or'' at the end;
       (ii) in subparagraph (B), by striking the period at the end 
     and inserting ``; or''; and
       (iii) by adding at the end the following new subparagraph:
       ``(C) in the case of a biosimilar biological product (as 
     defined in subsection (c)(6)(H)), the amount determined under 
     paragraph (8).''; and
       (B) by adding at the end the following new paragraph:
       ``(8) Biosimilar biological product.--The amount specified 
     in this paragraph for a biosimilar biological product 
     described in paragraph (1)(C) is the sum of--
       ``(A) the average sales price as determined using the 
     methodology described under paragraph (6) applied to a 
     biosimilar biological product for all National Drug Codes 
     assigned to such product in the same manner as such paragraph 
     is applied to drugs described in such paragraph; and
       ``(B) 6 percent of the amount determined under paragraph 
     (4) for the reference biological product (as defined in 
     subsection (c)(6)(I)).''; and
       (2) in subsection (c)(6), by adding at the end the 
     following new subparagraph:
       ``(H) Biosimilar biological product.--The term `biosimilar 
     biological product' means a biological product approved under 
     an abbreviated application for a license of a biological 
     product that relies in part on data or information in an 
     application for another biological product licensed under 
     section 351 of the Public Health Service Act.
       ``(I) Reference biological product.--The term `reference 
     biological product' means the biological product licensed 
     under such section 351 that is referred to in the application 
     described in subparagraph (H) of the biosimilar biological 
     product.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to payments for biosimilar biological products 
     beginning with the first day of the second calendar quarter 
     after enactment of legislation providing for a biosimilar 
     pathway (as determined by the Secretary).

     SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEMONSTRATION 
                   PROGRAM.

       (a) Establishment.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish a Medicare Hospice Concurrent Care demonstration 
     program at participating hospice programs under which 
     Medicare beneficiaries are furnished, during the same period, 
     hospice care and any other items or services covered under 
     title XVIII of the Social Security Act (42 U.S.C. 1395 et 
     seq.) from funds otherwise paid under such title to such 
     hospice programs.
       (2) Duration.--The demonstration program under this section 
     shall be conducted for a 3-year period.
       (3) Sites.--The Secretary shall select not more than 15 
     hospice programs at which the demonstration program under 
     this section shall be conducted. Such hospice programs shall 
     be located in urban and rural areas.
       (b) Independent Evaluation and Reports.--
       (1) Independent evaluation.--The Secretary shall provide 
     for the conduct of an independent evaluation of the 
     demonstration program under this section. Such independent 
     evaluation shall determine whether the demonstration program 
     has improved patient care, quality of life, and cost-
     effectiveness for Medicare beneficiaries participating in the 
     demonstration program.
       (2) Reports.--The Secretary shall submit to Congress a 
     report containing the results of the evaluation conducted 
     under paragraph (1), together with such recommendations as 
     the Secretary determines appropriate.
       (c) Budget Neutrality.--With respect to the 3-year period 
     of the demonstration program under this section, the 
     Secretary shall ensure that the aggregate expenditures under 
     title XVIII for such period shall not exceed the aggregate 
     expenditures that would have been expended under such title 
     if the demonstration program under this section had not been 
     implemented.

     SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NATIONAL 
                   BASIS IN THE CALCULATION OF THE MEDICARE 
                   HOSPITAL WAGE INDEX FLOOR.

       In the case of discharges occurring on or after October 1, 
     2010, for purposes of applying section 4410 of the Balanced 
     Budget Act of 1997 (42 U.S.C. 1395ww note) and paragraph 
     (h)(4) of section 412.64 of title 42, Code of Federal 
     Regulations, the Secretary of Health and Human Services shall 
     administer subsection (b) of such section 4410 and paragraph 
     (e) of such section 412.64 in the same manner as the 
     Secretary administered such subsection (b) and paragraph (e) 
     for discharges occurring during fiscal year 2008 (through a 
     uniform, national adjustment to the area wage index).

     SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS.

       (a) Study.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     conduct a study on the need for an additional payment for 
     urban Medicare-dependent hospitals for inpatient hospital 
     services under section 1886 of the Social Security Act (42 
     U.S.C. 1395ww). Such study shall include an analysis of--
       (A) the Medicare inpatient margins of urban Medicare-
     dependent hospitals, as compared to other hospitals which 
     receive 1 or more additional payments or adjustments under 
     such section (including those payments or adjustments 
     described in paragraph (2)(A)); and
       (B) whether payments to medicare-dependent, small rural 
     hospitals under subsection (d)(5)(G) of such section should 
     be applied to urban Medicare-dependent hospitals.
       (2) Urban medicare-dependent hospital defined.--For 
     purposes of this section, the term ``urban Medicare-dependent 
     hospital'' means a subsection (d) hospital (as defined in 
     subsection (d)(1)(B) of such section) that--
       (A) does not receive any additional payment or adjustment 
     under such section, such as payments for indirect medical 
     education costs under subsection (d)(5)(B) of such section, 
     disproportionate share payments under subsection (d)(5)(A) of 
     such section, payments to a rural referral center under 
     subsection (d)(5)(C) of such section, payments to a critical 
     access hospital under section 1814(l) of such Act (42 U.S.C. 
     1395f(l)), payments to a sole community hospital under 
     subsection (d)(5)(D) of such section 1886, or payments to a 
     medicare-dependent, small rural hospital under subsection 
     (d)(5)(G) of such section 1886; and
       (B) for which more than 60 percent of its inpatient days or 
     discharges during 2 of the 3 most recently audited cost 
     reporting periods for which the Secretary has a settled cost 
     report were attributable to inpatients entitled to benefits 
     under part A of title XVIII of such Act.
       (b) Report.--Not later than 9 months after the date of 
     enactment of this Act, the Secretary shall submit to Congress 
     a report containing the results of the study conducted under 
     subsection (a), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.

     SEC. 3143. PROTECTING HOME HEALTH BENEFITS.

       Nothing in the provisions of, or amendments made by, this 
     Act shall result in the reduction of guaranteed home health 
     benefits under title XVIII of the Social Security Act.

[[Page 4290]]



               Subtitle C--Provisions Relating to Part C

     SEC. 3201. MEDICARE ADVANTAGE PAYMENT.

       (a) MA Benchmark Based on Plan's Competitive Bids.--
       (1) In general.--Section 1853(j) of the Social Security Act 
     (42 U.S.C. 1395w-23(j)) is amended--
       (A) by striking ``Amounts.--For purposes'' and inserting 
     ``Amounts.--
       ``(1) In general.--For purposes'';
       (B) by redesignating paragraphs (1) and (2) as 
     subparagraphs (A) and (B), respectively, and indenting the 
     subparagraphs appropriately;
       (C) in subparagraph (A), as redesignated by subparagraph 
     (B)--
       (i) by redesignating subparagraphs (A) and (B) as clauses 
     (i) and (ii), respectively, and indenting the clauses 
     appropriately; and
       (ii) in clause (i), as redesignated by clause (i), by 
     striking ``an amount equal to'' and all that follows through 
     the end and inserting ``an amount equal to--

       ``(I) for years before 2007, \1/12\ of the annual MA 
     capitation rate under section 1853(c)(1) for the area for the 
     year, adjusted as appropriate for the purpose of risk 
     adjustment;
       ``(II) for 2007 through 2011, \1/12\ of the applicable 
     amount determined under subsection (k)(1) for the area for 
     the year;
       ``(III) for 2012, the sum of--

       ``(aa) \2/3\ of the quotient of--
       ``(AA) the applicable amount determined under subsection 
     (k)(1) for the area for the year; and
       ``(BB) 12; and
       ``(bb) \1/3\ of the MA competitive benchmark amount 
     (determined under paragraph (2)) for the area for the month;

       ``(IV) for 2013, the sum of--

       ``(aa) \1/3\ of the quotient of--
       ``(AA) the applicable amount determined under subsection 
     (k)(1) for the area for the year; and
       ``(BB) 12; and
       ``(bb) \2/3\ of the MA competitive benchmark amount (as so 
     determined) for the area for the month;

       ``(V) for 2014, the MA competitive benchmark amount for the 
     area for a month in 2013 (as so determined), increased by the 
     national per capita MA growth percentage, described in 
     subsection (c)(6) for 2014, but not taking into account any 
     adjustment under subparagraph (C) of such subsection for a 
     year before 2004; and
       ``(VI) for 2015 and each subsequent year, the MA 
     competitive benchmark amount (as so determined) for the area 
     for the month; or'';

       (iii) in clause (ii), as redesignated by clause (i), by 
     striking ``subparagraph (A)'' and inserting ``clause (i)'';
       (D) by adding at the end the following new paragraphs:
       ``(2) Computation of ma competitive benchmark amount.--
       ``(A) In general.--Subject to subparagraph (B) and 
     paragraph (3), for months in each year (beginning with 2012) 
     for each MA payment area the Secretary shall compute an MA 
     competitive benchmark amount equal to the weighted average of 
     the unadjusted MA statutory non-drug monthly bid amount (as 
     defined in section 1854(b)(2)(E)) for each MA plan in the 
     area, with the weight for each plan being equal to the 
     average number of beneficiaries enrolled under such plan in 
     the reference month (as defined in section 1858(f)(4), except 
     that, in applying such definition for purposes of this 
     paragraph, `to compute the MA competitive benchmark amount 
     under section 1853(j)(2)' shall be substituted for `to 
     compute the percentage specified in subparagraph (A) and 
     other relevant percentages under this part').
       ``(B) Weighting rules.--
       ``(i) Single plan rule.--In the case of an MA payment area 
     in which only a single MA plan is being offered, the weight 
     under subparagraph (A) shall be equal to 1.
       ``(ii) Use of simple average among multiple plans if no 
     plans offered in previous year.--In the case of an MA payment 
     area in which no MA plan was offered in the previous year and 
     more than 1 MA plan is offered in the current year, the 
     Secretary shall use a simple average of the unadjusted MA 
     statutory non-drug monthly bid amount (as so defined) for 
     purposes of computing the MA competitive benchmark amount 
     under subparagraph (A).
       ``(3) Cap on ma competitive benchmark amount.--In no case 
     shall the MA competitive benchmark amount for an area for a 
     month in a year be greater than the applicable amount that 
     would (but for the application of this subsection) be 
     determined under subsection (k)(1) for the area for the month 
     in the year.''; and
       (E) in subsection (k)(2)(B)(ii)(III), by striking 
     ``(j)(1)(A)'' and inserting ``(j)(1)(A)(i)''.
       (2) Conforming amendments.--
       (A) Section 1853(k)(2) of the Social Security Act (42 
     U.S.C. 1395w-23(k)(2)) is amended--
       (i) in subparagraph (A), by striking ``through 2010'' and 
     inserting ``and subsequent years''; and
       (ii) in subparagraph (C)--

       (I) in clause (iii), by striking ``and'' at the end;
       (II) in clause (iv), by striking the period at the end and 
     inserting ``; and''; and
       (III) by adding at the end the following new clause:

       ``(v) for 2011 and subsequent years, 0.00.''.
       (B) Section 1854(b) of the Social Security Act (42 U.S.C. 
     1395w-24(b)) is amended--
       (i) in paragraph (3)(B)(i), by striking ``1853(j)(1)'' and 
     inserting ``1853(j)(1)(A)''; and
       (ii) in paragraph (4)(B)(i), by striking ``1853(j)(2)'' and 
     inserting ``1853(j)(1)(B)''.
       (C) Section 1858(f) of the Social Security Act (42 U.S.C. 
     1395w-27(f)) is amended--
       (i) in paragraph (1), by striking ``1853(j)(2)'' and 
     inserting ``1853(j)(1)(B)''; and
       (ii) in paragraph (3)(A), by striking ``1853(j)(1)(A)'' and 
     inserting ``1853(j)(1)(A)(i)''.
       (D) Section 1860C-1(d)(1)(A) of the Social Security Act (42 
     U.S.C. 1395w-29(d)(1)(A)) is amended by striking 
     ``1853(j)(1)(A)'' and inserting ``1853(j)(1)(A)(i)''.
       (b) Reduction of National Per Capita Growth Percentage for 
     2011.--Section 1853(c)(6) of the Social Security Act (42 
     U.S.C. 1395w-23(c)(6)) is amended--
       (1) in clause (v), by striking ``and'' at the end;
       (2) in clause (vi)--
       (A) by striking ``for a year after 2002'' and inserting 
     ``for 2003 through 2010''; and
       (B) by striking the period at the end and inserting a 
     comma; and
       (C) by adding at the end the following new clauses:
       ``(vii) for 2011, 3 percentage points; and
       ``(viii) for a year after 2011, 0 percentage points.''.
       (c) Enhancement of Beneficiary Rebates.--Section 
     1854(b)(1)(C)(i) of the Social Security Act (42 U.S.C. 1395w-
     24(b)(1)(C)(i)) is amended by inserting ``(or 100 percent in 
     the case of plan years beginning on or after January 1, 
     2014)'' after ``75 percent''.
       (d) Bidding Rules.--
       (1) Requirements for information submitted.--Section 
     1854(a)(6)(A) of the Social Security Act (42 U.S.C. 1395w-
     24(a)(6)(A)) is amended, in the flush matter following clause 
     (v), by adding at the end the following sentence: 
     ``Information to be submitted under this paragraph shall be 
     certified by a qualified member of the American Academy of 
     Actuaries and shall meet actuarial guidelines and rules 
     established by the Secretary under subparagraph (B)(v).''.
       (2) Establishment of actuarial guidelines.--Section 
     1854(a)(6)(B) of the Social Security Act (42 U.S.C. 1395w-
     24(a)(6)(B)) is amended--
       (A) in clause (i), by striking ``(iii) and (iv)'' and 
     inserting ``(iii), (iv), and (v)''; and
       (B) by adding at the end the following new clause:
       ``(v) Establishment of actuarial guidelines.--

       ``(I) In general.--In order to establish fair MA 
     competitive benchmarks under section 1853(j)(1)(A)(i), the 
     Secretary, acting through the Chief Actuary of the Centers 
     for Medicare & Medicaid Services (in this clause referred to 
     as the `Chief Actuary'), shall establish--

       ``(aa) actuarial guidelines for the submission of bid 
     information under this paragraph; and
       ``(bb) bidding rules that are appropriate to ensure 
     accurate bids and fair competition among MA plans.

       ``(II) Denial of bid amounts.--The Secretary shall deny 
     monthly bid amounts submitted under subparagraph (A) that do 
     not meet the actuarial guidelines and rules established under 
     subclause (I).
       ``(III) Refusal to accept certain bids due to 
     misrepresentations and failures to adequately meet 
     requirements.--In the case where the Secretary determines 
     that information submitted by an MA organization under 
     subparagraph (A) contains consistent misrepresentations and 
     failures to adequately meet requirements of the organization, 
     the Secretary may refuse to accept any additional such bid 
     amounts from the organization for the plan year and the Chief 
     Actuary shall, if the Chief Actuary determines that the 
     actuaries of the organization were complicit in those 
     misrepresentations and failures, report those actuaries to 
     the Actuarial Board for Counseling and Discipline.''.

       (3) Effective date.--The amendments made by this subsection 
     shall apply to bid amounts submitted on or after January 1, 
     2012.
       (e) MA Local Plan Service Areas.--
       (1) In general.--Section 1853(d) of the Social Security Act 
     (42 U.S.C. 1395w-23(d)) is amended--
       (A) in the subsection heading, by striking ``MA Region'' 
     and inserting ``MA Region; MA Local Plan Service Area'';
       (B) in paragraph (1), by striking subparagraph (A) and 
     inserting the following:
       ``(A) with respect to an MA local plan--
       ``(i) for years before 2012, an MA local area (as defined 
     in paragraph (2)); and
       ``(ii) for 2012 and succeeding years, a service area that 
     is an entire urban or rural area, as applicable (as described 
     in paragraph (5)); and''; and
       (C) by adding at the end the following new paragraph:
       ``(5) MA local plan service area.--For 2012 and succeeding 
     years, the service area for an MA local plan shall be an 
     entire urban or rural area in each State as follows:
       ``(A) Urban areas.--
       ``(i) In general.--Subject to clause (ii) and subparagraphs 
     (C) and (D), the service area for an MA local plan in an 
     urban area shall be the Core Based Statistical Area (in this 
     paragraph referred to as a `CBSA') or, if applicable, a 
     conceptually similar alternative classification, as defined 
     by the Director of the Office of Management and Budget.
       ``(ii) CBSA covering more than one state.--In the case of a 
     CBSA (or alternative classification) that covers more than 
     one State, the Secretary shall divide the CBSA (or 
     alternative classification) into separate service areas with 
     respect to each State covered by the CBSA (or alternative 
     classification).
       ``(B) Rural areas.--Subject to subparagraphs (C) and (D), 
     the service area for an MA local plan in a rural area shall 
     be a county that does

[[Page 4291]]

     not qualify for inclusion in a CBSA (or alternative 
     classification), as defined by the Director of the Office of 
     Management and Budget.
       ``(C) Refinements to service areas.--For 2015 and 
     succeeding years, in order to reflect actual patterns of 
     health care service utilization, the Secretary may adjust the 
     boundaries of service areas for MA local plans in urban areas 
     and rural areas under subparagraphs (A) and (B), 
     respectively, but may only do so based on recent analyses of 
     actual patterns of care.
       ``(D) Additional authority to make limited exceptions to 
     service area requirements for ma local plans.--The Secretary 
     may, in addition to any adjustments under subparagraph (C), 
     make limited exceptions to service area requirements 
     otherwise applicable under this part for MA local plans that 
     have in effect (as of the date of enactment of the Patient 
     Protection and Affordable Care Act)--
       ``(i) agreements with another MA organization or MA plan 
     that preclude the offering of benefits throughout an entire 
     service area; or
       ``(ii) limitations in their structural capacity to support 
     adequate networks throughout an entire service area as a 
     result of the delivery system model of the MA local plan.''.
       (2) Conforming amendments.--
       (A) In general.--
       (i) Section 1851(b)(1) of the Social Security Act (42 
     U.S.C. 1395w-21(b)(1)) is amended by striking subparagraph 
     (C).
       (ii) Section 1853(b)(1)(B)(i) of such Act (42 U.S.C. 1395w-
     23(b)(1)(B)(i))--

       (I) in the matter preceding subclause (I), by striking ``MA 
     payment area'' and inserting ``MA local area (as defined in 
     subsection (d)(2))''; and
       (II) in subclause (I), by striking ``MA payment area'' and 
     inserting ``MA local area (as so defined)''.

       (iii) Section 1853(b)(4) of such Act (42 U.S.C. 1395w-
     23(b)(4)) is amended by striking ``Medicare Advantage payment 
     area'' and inserting ``MA local area (as so defined)''.
       (iv) Section 1853(c)(1) of such Act (42 U.S.C. 1395w-
     23(c)(1)) is amended--

       (I) in the matter preceding subparagraph (A), by striking 
     ``a Medicare Advantage payment area that is''; and
       (II) in subparagraph (D)(i), by striking ``MA payment 
     area'' and inserting ``MA local area (as defined in 
     subsection (d)(2))''.

       (v) Section 1854 of such Act (42 U.S.C. 1395w-24) is 
     amended by striking subsection (h).
       (B) Effective date.--The amendments made by this paragraph 
     shall take effect on January 1, 2012.
       (f) Performance Bonuses.--
       (1) MA plans.--
       (A) In general.--Section 1853 of the Social Security Act 
     (42 U.S.C. 1395w-23) is amended by adding at the end the 
     following new subsection:
       ``(n) Performance Bonuses.--
       ``(1) Care coordination and management performance bonus.--
       ``(A) In general.--For years beginning with 2014, subject 
     to subparagraph (B), in the case of an MA plan that conducts 
     1 or more programs described in subparagraph (C) with respect 
     to the year, the Secretary shall, in addition to any other 
     payment provided under this part, make monthly payments, with 
     respect to coverage of an individual under this part, to the 
     MA plan in an amount equal to the product of--
       ``(i) 0.5 percent of the national monthly per capita cost 
     for expenditures for individuals enrolled under the original 
     medicare fee-for-service program for the year; and
       ``(ii) the total number of programs described in clauses 
     (i) through (ix) of subparagraph (C) that the Secretary 
     determines the plan is conducting for the year under such 
     subparagraph.
       ``(B) Limitation.--In no case may the total amount of 
     payment with respect to a year under subparagraph (A) be 
     greater than 2 percent of the national monthly per capita 
     cost for expenditures for individuals enrolled under the 
     original medicare fee-for-service program for the year, as 
     determined prior to the application of risk adjustment under 
     paragraph (4).
       ``(C) Programs described.--The following programs are 
     described in this paragraph:
       ``(i) Care management programs that--

       ``(I) target individuals with 1 or more chronic conditions;
       ``(II) identify gaps in care; and
       ``(III) facilitate improved care by using additional 
     resources like nurses, nurse practitioners, and physician 
     assistants.

       ``(ii) Programs that focus on patient education and self-
     management of health conditions, including interventions 
     that--

       ``(I) help manage chronic conditions;
       ``(II) reduce declines in health status; and
       ``(III) foster patient and provider collaboration.

       ``(iii) Transitional care interventions that focus on care 
     provided around a hospital inpatient episode, including 
     programs that target post-discharge patient care in order to 
     reduce unnecessary health complications and readmissions.
       ``(iv) Patient safety programs, including provisions for 
     hospital-based patient safety programs in contracts that the 
     Medicare Advantage organization offering the MA plan has with 
     hospitals.
       ``(v) Financial policies that promote systematic 
     coordination of care by primary care physicians across the 
     full spectrum of specialties and sites of care, such as 
     medical homes, capitation arrangements, or pay-for-
     performance programs.
       ``(vi) Programs that address, identify, and ameliorate 
     health care disparities among principal at-risk 
     subpopulations.
       ``(vii) Medication therapy management programs that are 
     more extensive than is required under section 1860D-4(c) (as 
     determined by the Secretary).
       ``(viii) Health information technology programs, including 
     clinical decision support and other tools to facilitate data 
     collection and ensure patient-centered, appropriate care.
       ``(ix) Such other care management and coordination programs 
     as the Secretary determines appropriate.
       ``(D) Conduct of program in urban and rural areas.--An MA 
     plan may conduct a program described in subparagraph (C) in a 
     manner appropriate for an urban or rural area, as applicable.
       ``(E) Reporting of data.--Each Medicare Advantage 
     organization shall provide to the Secretary the information 
     needed to determine whether they are eligible for a care 
     coordination and management performance bonus at a time and 
     in a manner specified by the Secretary.
       ``(F) Periodic auditing.--The Secretary shall provide for 
     the annual auditing of programs described in subparagraph (C) 
     for which an MA plan receives a care coordination and 
     management performance bonus under this paragraph. The 
     Comptroller General shall monitor auditing activities 
     conducted under this subparagraph.
       ``(2) Quality performance bonuses.--
       ``(A) Quality bonus.--For years beginning with 2014, the 
     Secretary shall, in addition to any other payment provided 
     under this part, make monthly payments, with respect to 
     coverage of an individual under this part, to an MA plan that 
     achieves at least a 3 star rating (or comparable rating) on a 
     rating system described in subparagraph (C) in an amount 
     equal to--
       ``(i) in the case of a plan that achieves a 3 star rating 
     (or comparable rating) on such system 2 percent of the 
     national monthly per capita cost for expenditures for 
     individuals enrolled under the original medicare fee-for-
     service program for the year; and
       ``(ii) in the case of a plan that achieves a 4 or 5 star 
     rating (or comparable rating on such system, 4 percent of 
     such national monthly per capita cost for the year.
       ``(B) Improved quality bonus.--For years beginning with 
     2014, in the case of an MA plan that does not receive a 
     quality bonus under subparagraph (A) and is an improved 
     quality MA plan with respect to the year (as identified by 
     the Secretary), the Secretary shall, in addition to any other 
     payment provided under this part, make monthly payments, with 
     respect to coverage of an individual under this part, to the 
     MA plan in an amount equal to 1 percent of such national 
     monthly per capita cost for the year.
       ``(C) Use of rating system.--For purposes of subparagraph 
     (A), a rating system described in this paragraph is--
       ``(i) a rating system that uses up to 5 stars to rate 
     clinical quality and enrollee satisfaction and performance at 
     the Medicare Advantage contract or MA plan level; or
       ``(ii) such other system established by the Secretary that 
     provides for the determination of a comparable quality 
     performance rating to the rating system described in clause 
     (i).
       ``(D) Data used in determining score.--
       ``(i) In general.--The rating of an MA plan under the 
     rating system described in subparagraph (C) with respect to a 
     year shall be based on based on the most recent data 
     available.
       ``(ii) Plans that fail to report data.--An MA plan which 
     does not report data that enables the Secretary to rate the 
     plan for purposes of subparagraph (A) or identify the plan 
     for purposes of subparagraph (B) shall be counted, for 
     purposes of such rating or identification, as having the 
     lowest plan performance rating and the lowest percentage 
     improvement, respectively.
       ``(3) Quality bonus for new and low enrollment ma plans.--
       ``(A) New ma plans.--For years beginning with 2014, in the 
     case of an MA plan that first submits a bid under section 
     1854(a)(1)(A) for 2012 or a subsequent year, only receives 
     enrollments made during the coverage election periods 
     described in section 1851(e), and is not able to receive a 
     bonus under subparagraph (A) or (B) of paragraph (2) for the 
     year, the Secretary shall, in addition to any other payment 
     provided under this part, make monthly payments, with respect 
     to coverage of an individual under this part, to the MA plan 
     in an amount equal to 2 percent of national monthly per 
     capita cost for expenditures for individuals enrolled under 
     the original medicare fee-for-service program for the year. 
     In its fourth year of operation, the MA plan shall be paid in 
     the same manner as other MA plans with comparable enrollment.
       ``(B) Low enrollment plans.--For years beginning with 2014, 
     in the case of an MA plan that has low enrollment (as defined 
     by the Secretary) and would not otherwise be able to receive 
     a bonus under subparagraph (A) or (B) of paragraph (2) or 
     subparagraph (A) of this paragraph for the year (referred to 
     in this subparagraph as a `low enrollment plan'), the 
     Secretary shall use a regional or local mean of the rating of 
     all MA plans in the region or local area, as determined 
     appropriate by the Secretary, on measures used to determine 
     whether MA plans are eligible for a quality or an improved 
     quality bonus, as applicable, to determine whether the low 
     enrollment plan is eligible for a bonus under such a 
     subparagraph.
       ``(4) Risk adjustment.--The Secretary shall risk adjust a 
     performance bonus under this subsection in the same manner as 
     the Secretary risk adjusts beneficiary rebates described in 
     section 1854(b)(1)(C).

[[Page 4292]]

       ``(5) Notification.--The Secretary, in the annual 
     announcement required under subsection (b)(1)(B) for 2014 and 
     each succeeding year, shall notify the Medicare Advantage 
     organization of any performance bonus (including a care 
     coordination and management performance bonus under paragraph 
     (1), a quality performance bonus under paragraph (2), and a 
     quality bonus for new and low enrollment plans under 
     paragraph (3)) that the organization will receive under this 
     subsection with respect to the year. The Secretary shall 
     provide for the publication of the information described in 
     the previous sentence on the Internet website of the Centers 
     for Medicare & Medicaid Services.''
       (B) Conforming amendment.--Section 1853(a)(1)(B) of the 
     Social Security Act (42 U.S.C. 1395w-23(a)(1)(B)) is 
     amended--
       (i) in clause (i), by inserting ``and any performance bonus 
     under subsection (n)'' before the period at the end; and
       (ii) in clause (ii), by striking ``(G)'' and inserting 
     ``(G), plus the amount (if any) of any performance bonus 
     under subsection (n)''.
       (2) Application of performance bonuses to ma regional 
     plans.--Section 1858 of the Social Security Act (42 U.S.C. 
     1395w-27a) is amended--
       (A) in subsection (f)(1), by striking ``subsection (e)'' 
     and inserting ``subsections (e) and (i)''; and
       (B) by adding at the end the following new subsection:
       ``(i) Application of Performance Bonuses to MA Regional 
     Plans.--For years beginning with 2014, the Secretary shall 
     apply the performance bonuses under section 1853(n) (relating 
     to bonuses for care coordination and management, quality 
     performance, and new and low enrollment MA plans) to MA 
     regional plans in a similar manner as such performance 
     bonuses apply to MA plans under such subsection.''.
       (g) Grandfathering Supplemental Benefits for Current 
     Enrollees After Implementation of Competitive Bidding.--
     Section 1853 of the Social Security Act (42 U.S.C. 1395w-23), 
     as amended by subsection (f), is amended by adding at the end 
     the following new subsection:
       ``(o) Grandfathering Supplemental Benefits for Current 
     Enrolles After Implementation of Competitive Bidding.--
       ``(1) Identification of areas.--The Secretary shall 
     identify MA local areas in which, with respect to 2009, 
     average bids submitted by an MA organization under section 
     1854(a) for MA local plans in the area are not greater than 
     75 percent of the adjusted average per capita cost for the 
     year involved, determined under section 1876(a)(4), for the 
     area for individuals who are not enrolled in an MA plan under 
     this part for the year, but adjusted to exclude costs 
     attributable to payments under section 1848(o), 1886(n), and 
     1886(h).
       ``(2) Election to provide rebates to grandfathered 
     enrollees.--
       ``(A) In general.--For years beginning with 2012, each 
     Medicare Advantage organization offering an MA local plan in 
     an area identified by the Secretary under paragraph (1) may 
     elect to provide rebates to grandfathered enrollees under 
     section 1854(b)(1)(C). In the case where an MA organization 
     makes such an election, the monthly per capita dollar amount 
     of such rebates shall not exceed the applicable amount for 
     the year (as defined in subparagraph (B)).
       ``(B) Applicable amount.--For purposes of this subsection, 
     the term `applicable amount' means--
       ``(i) for 2012, the monthly per capita dollar amount of 
     such rebates provided to enrollees under the MA local plan 
     with respect to 2011; and
       ``(ii) for a subsequent year, 95 percent of the amount 
     determined under this subparagraph for the preceding year.
       ``(3) Special rules for plans in identified areas.--
     Notwithstanding any other provision of this part, the 
     following shall apply with respect to each Medicare Advantage 
     organization offering an MA local plan in an area identified 
     by the Secretary under paragraph (1) that makes an election 
     described in paragraph (2):
       ``(A) Payments.--The amount of the monthly payment under 
     this section to the Medicare Advantage organization, with 
     respect to coverage of a grandfathered enrollee under this 
     part in the area for a month, shall be equal to--
       ``(i) for 2012 and 2013, the sum of--

       ``(I) the bid amount under section 1854(a) for the MA local 
     plan; and
       ``(II) the applicable amount (as defined in paragraph 
     (2)(B)) for the MA local plan for the year.

       ``(ii) for 2014 and subsequent years, the sum of--

       ``(I) the MA competitive benchmark amount under subsection 
     (j)(1)(A)(i) for the area for the month, adjusted, only to 
     the extent the Secretary determines necessary, to account for 
     induced utilization as a result of rebates provided to 
     grandfathered enrollees (except that such adjustment shall 
     not exceed 0.5 percent of such MA competitive benchmark 
     amount); and
       ``(II) the applicable amount (as so defined) for the MA 
     local plan for the year.

       ``(B) Requirement to submit bids under competitive 
     bidding.--The Medicare Advantage organization shall submit a 
     single bid amount under section 1854(a) for the MA local 
     plan. The Medicare Advantage organization shall remove from 
     such bid amount any effects of induced demand for care that 
     may result from the higher rebates available to grandfathered 
     enrollees under this subsection.
       ``(C) Nonapplication of bonus payments and any other 
     rebates.--The Medicare Advantage organization offering the MA 
     local plan shall not be eligible for any bonus payment under 
     subsection (n) or any rebate under this part (other than as 
     provided under this subsection) with respect to grandfathered 
     enrollees.
       ``(D) Nonapplication of uniform bid and premium amounts to 
     grandfathered enrollees.--Section 1854(c) shall not apply 
     with respect to the MA local plan.
       ``(E) Nonapplication of limitation on application of plan 
     rebates toward payment of part b premium.--Notwithstanding 
     clause (iii) of section 1854(b)(1)(C), in the case of a 
     grandfathered enrollee, a rebate under such section may be 
     used for the purpose described in clause (ii)(III) of such 
     section.
       ``(F) Risk adjustment.--The Secretary shall risk adjust 
     rebates to grandfathered enrollees under this subsection in 
     the same manner as the Secretary risk adjusts beneficiary 
     rebates described in section 1854(b)(1)(C).
       ``(4) Definition of grandfathered enrollee.--In this 
     subsection, the term `grandfathered enrollee' means an 
     individual who is enrolled (effective as of the date of 
     enactment of this subsection) in an MA local plan in an area 
     that is identified by the Secretary under paragraph (1).''.
       (h) Transitional Extra Benefits.--Section 1853 of the 
     Social Security Act (42 U.S.C. 1395w-23), as amended by 
     subsections (f) and (g), is amended by adding at the end the 
     following new subsection:
       ``(p) Transitional Extra Benefits.--
       ``(1) In general.--For years beginning with 2012, the 
     Secretary shall provide transitional rebates under section 
     1854(b)(1)(C) for the provision of extra benefits (as 
     specified by the Secretary) to enrollees described in 
     paragraph (2).
       ``(2) Enrollees described.--An enrollee described in this 
     paragraph is an individual who--
       ``(A) enrolls in an MA local plan in an applicable area; 
     and
       ``(B) experiences a significant reduction in extra benefits 
     described in clause (ii) of section 1854(b)(1)(C) as a result 
     of competitive bidding under this part (as determined by the 
     Secretary).
       ``(3) Applicable areas.--In this subsection, the term 
     `applicable area' means the following:
       ``(A) The 2 largest metropolitan statistical areas, if the 
     Secretary determines that the total amount of such extra 
     benefits for each enrollee for the month in those areas is 
     greater than $100.
       ``(B) A county where--
       ``(i) the MA area-specific non-drug monthly benchmark 
     amount for a month in 2011 is equal to the legacy urban floor 
     amount (as described in subsection (c)(1)(B)(iii)), as 
     determined by the Secretary for the area for 2011;
       ``(ii) the percentage of Medicare Advantage eligible 
     beneficiaries in the county who are enrolled in an MA plan 
     for 2009 is greater than 30 percent (as determined by the 
     Secretary); and
       ``(iii) average bids submitted by an MA organization under 
     section 1854(a) for MA local plans in the county for 2011 are 
     not greater than the adjusted average per capita cost for the 
     year involved, determined under section 1876(a)(4), for the 
     county for individuals who are not enrolled in an MA plan 
     under this part for the year, but adjusted to exclude costs 
     attributable to payments under section 1848(o), 1886(n), and 
     1886(h).
       ``(C) If the Secretary determines appropriate, a county 
     contiguous to an area or county described in subparagraph (A) 
     or (B), respectively.
       ``(4) Review of plan bids.--In the case of a bid submitted 
     by an MA organization under section 1854(a) for an MA local 
     plan in an applicable area, the Secretary shall review such 
     bid in order to ensure that extra benefits (as specified by 
     the Secretary) are provided to enrollees described in 
     paragraph (2).
       ``(5) Funding.--The Secretary shall provide for the 
     transfer from the Federal Hospital Insurance Trust Fund under 
     section 1817 and the Federal Supplementary Medical Insurance 
     Trust Fund established under section 1841, in such proportion 
     as the Secretary determines appropriate, of an amount not to 
     exceed $5,000,000,000 for the period of fiscal years 2012 
     through 2019 for the purpose of providing transitional 
     rebates under section 1854(b)(1)(C) for the provision of 
     extra benefits under this subsection.''.
       (i) Nonapplication of Competitive Bidding and Related 
     Provisions and Clarification of MA Payment Area for PACE 
     Programs.--
       (1) Nonapplication of competitive bidding and related 
     provisions for pace programs.--Section 1894 of the Social 
     Security Act (42 U.S.C. 1395eee) is amended--
       (A) by redesignating subsections (h) and (i) as subsections 
     (i) and (j), respectively;
       (B) by inserting after subsection (g) the following new 
     subsection:
       ``(h) Nonapplication of Competitive Bidding and Related 
     Provisions Under Part C.--With respect to a PACE program 
     under this section, the following provisions (and regulations 
     relating to such provisions) shall not apply:
       ``(1) Section 1853(j)(1)(A)(i), relating to MA area-
     specific non-drug monthly benchmark amount being based on 
     competitive bids.
       ``(2) Section 1853(d)(5), relating to the establishment of 
     MA local plan service areas.
       ``(3) Section 1853(n), relating to the payment of 
     performance bonuses.
       ``(4) Section 1853(o), relating to grandfathering 
     supplemental benefits for current enrollees after 
     implementation of competitive bidding.
       ``(5) Section 1853(p), relating to transitional extra 
     benefits.''.

[[Page 4293]]

       (2) Special rule for ma payment area for pace programs.--
     Section 1853(d) of the Social Security Act (42 U.S.C. 1395w-
     23(d)), as amended by subsection (e), is amended by adding at 
     the end the following new paragraph:
       ``(6) Special rule for ma payment area for pace programs.--
     For years beginning with 2012, in the case of a PACE program 
     under section 1894, the MA payment area shall be the MA local 
     area (as defined in paragraph (2)).''.

     SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION.

       (a) Limitation on Variation of Cost Sharing for Certain 
     Benefits.--
       (1) In general.--Section 1852(a)(1)(B) of the Social 
     Security Act (42 U.S.C. 1395w-22(a)(1)(B)) is amended--
       (A) in clause (i), by inserting ``, subject to clause 
     (iii),'' after ``and B or''; and
       (B) by adding at the end the following new clauses:
       ``(iii) Limitation on variation of cost sharing for certain 
     benefits.--Subject to clause (v), cost-sharing for services 
     described in clause (iv) shall not exceed the cost-sharing 
     required for those services under parts A and B.
       ``(iv) Services described.--The following services are 
     described in this clause:

       ``(I) Chemotherapy administration services.
       ``(II) Renal dialysis services (as defined in section 
     1881(b)(14)(B)).
       ``(III) Skilled nursing care.
       ``(IV) Such other services that the Secretary determines 
     appropriate (including services that the Secretary determines 
     require a high level of predictability and transparency for 
     beneficiaries).

       ``(v) Exception.--In the case of services described in 
     clause (iv) for which there is no cost-sharing required under 
     parts A and B, cost-sharing may be required for those 
     services in accordance with clause (i).''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to plan years beginning on or after January 1, 
     2011.
       (b) Application of Rebates, Performance Bonuses, and 
     Premiums.--
       (1) Application of rebates.--Section 1854(b)(1)(C) of the 
     Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)) is 
     amended--
       (A) in clause (ii), by striking ``rebate.--A rebate'' and 
     inserting ``rebate for plan years before 2012.--For plan 
     years before 2012, a rebate'';
       (B) by redesignating clauses (iii) and (iv) as clauses (iv) 
     and (v); and
       (C) by inserting after clause (ii) the following new 
     clause:
       ``(iii) Form of rebate for plan year 2012 and subsequent 
     plan years.--For plan years beginning on or after January 1, 
     2012, a rebate required under this subparagraph may not be 
     used for the purpose described in clause (ii)(III) and shall 
     be provided through the application of the amount of the 
     rebate in the following priority order:

       ``(I) First, to use the most significant share to 
     meaningfully reduce cost-sharing otherwise applicable for 
     benefits under the original medicare fee-for-service program 
     under parts A and B and for qualified prescription drug 
     coverage under part D, including the reduction of any 
     deductibles, copayments, and maximum limitations on out-of-
     pocket expenses otherwise applicable. Any reduction of 
     maximum limitations on out-of-pocket expenses under the 
     preceding sentence shall apply to all benefits under the 
     original medicare fee-for-service program option. The 
     Secretary may provide guidance on meaningfully reducing cost-
     sharing under this subclause, except that such guidance may 
     not require a particular amount of cost-sharing or reduction 
     in cost-sharing.
       ``(II) Second, to use the next most significant share to 
     meaningfully provide coverage of preventive and wellness 
     health care benefits (as defined by the Secretary) which are 
     not benefits under the original medicare fee-for-service 
     program, such as smoking cessation, a free flu shot, and an 
     annual physical examination.
       ``(III) Third, to use the remaining share to meaningfully 
     provide coverage of other health care benefits which are not 
     benefits under the original medicare fee-for-service program, 
     such as eye examinations and dental coverage, and are not 
     benefits described in subclause (II).''.

       (2) Application of performance bonuses.--Section 1853(n) of 
     the Social Security Act, as added by section 3201(f), is 
     amended by adding at the end the following new paragraph:
       ``(6) Application of performance bonuses.--For plan years 
     beginning on or after January 1, 2014, any performance bonus 
     paid to an MA plan under this subsection shall be used for 
     the purposes, and in the priority order, described in 
     subclauses (I) through (III) of section 
     1854(b)(1)(C)(iii).''.
       (3) Application of ma monthly supplementary beneficiary 
     premium.--Section 1854(b)(2)(C) of the Social Security Act 
     (42 U.S.C. 1395w-24(b)(2)(C)) is amended--
       (A) by striking ``Premium.--The term'' and inserting 
     ``premium.--
       ``(i) In general.--The term''; and
       (B) by adding at the end the following new clause:
       ``(ii) Application of ma monthly supplementary beneficiary 
     premium.--For plan years beginning on or after January 1, 
     2012, any MA monthly supplementary beneficiary premium 
     charged to an individual enrolled in an MA plan shall be used 
     for the purposes, and in the priority order, described in 
     subclauses (I) through (III) of paragraph (1)(C)(iii).''.

     SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING 
                   MA PAYMENT TRANSITION.

       Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 
     1395w-23(a)(1)(C)) is amended by adding at the end the 
     following new clause:
       ``(iii) Application of coding intensity adjustment for 2011 
     and subsequent years.--

       ``(I) Requirement to apply in 2011 through 2013.--In order 
     to ensure payment accuracy, the Secretary shall conduct an 
     analysis of the differences described in clause (ii)(I). The 
     Secretary shall ensure that the results of such analysis are 
     incorporated into the risk scores for 2011, 2012, and 2013.
       ``(II) Authority to apply in 2014 and subsequent years.--
     The Secretary may, as appropriate, incorporate the results of 
     such analysis into the risk scores for 2014 and subsequent 
     years.''.

     SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION 
                   PERIODS.

       (a) Annual 45-day Period for Disenrollment From MA Plans To 
     Elect To Receive Benefits Under the Original Medicare Fee-
     for-service Program.--
       (1) In general.--Section 1851(e)(2)(C) of the Social 
     Security Act (42 U.S.C. 1395w-1(e)(2)(C)) is amended to read 
     as follows:
       ``(C) Annual 45-day period for disenrollment from ma plans 
     to elect to receive benefits under the original medicare fee-
     for-service program.--Subject to subparagraph (D), at any 
     time during the first 45 days of a year (beginning with 
     2011), an individual who is enrolled in a Medicare Advantage 
     plan may change the election under subsection (a)(1), but 
     only with respect to coverage under the original medicare 
     fee-for-service program under parts A and B, and may elect 
     qualified prescription drug coverage in accordance with 
     section 1860D-1.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply with respect to 2011 and succeeding years.
       (b) Timing of the Annual, Coordinated Election Period Under 
     Parts C and D.--Section 1851(e)(3)(B) of the Social Security 
     Act (42 U.S.C. 1395w-1(e)(3)(B)) is amended--
       (1) in clause (iii), by striking ``and'' at the end;
       (2) in clause (iv)--
       (A) by striking ``and succeeding years'' and inserting ``, 
     2008, 2009, and 2010''; and
       (B) by striking the period at the end and inserting ``; 
     and''; and
       (3) by adding at the end the following new clause:
       ``(v) with respect to 2012 and succeeding years, the period 
     beginning on October 15 and ending on December 7 of the year 
     before such year.''.

     SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL 
                   NEEDS INDIVIDUALS.

       (a) Extension of SNP Authority.--Section 1859(f)(1) of the 
     Social Security Act (42 U.S.C. 1395w-28(f)(1)), as amended by 
     section 164(a) of the Medicare Improvements for Patients and 
     Providers Act of 2008 (Public Law 110-275), is amended by 
     striking ``2011'' and inserting ``2014''.
       (b) Authority To Apply Frailty Adjustment Under PACE 
     Payment Rules.--Section 1853(a)(1)(B) of the Social Security 
     Act (42 U.S.C. 1395w-23(a)(1)(B)) is amended by adding at the 
     end the following new clause:
       ``(iv) Authority to apply frailty adjustment under pace 
     payment rules for certain specialized ma plans for special 
     needs individuals.--

       ``(I) In general.--Notwithstanding the preceding provisions 
     of this paragraph, for plan year 2011 and subsequent plan 
     years, in the case of a plan described in subclause (II), the 
     Secretary may apply the payment rules under section 1894(d) 
     (other than paragraph (3) of such section) rather than the 
     payment rules that would otherwise apply under this part, but 
     only to the extent necessary to reflect the costs of treating 
     high concentrations of frail individuals.
       ``(II) Plan described.--A plan described in this subclause 
     is a specialized MA plan for special needs individuals 
     described in section 1859(b)(6)(B)(ii) that is fully 
     integrated with capitated contracts with States for Medicaid 
     benefits, including long-term care, and that have similar 
     average levels of frailty (as determined by the Secretary) as 
     the PACE program.''.

       (c) Transition and Exception Regarding Restriction on 
     Enrollment.--Section 1859(f) of the Social Security Act (42 
     U.S.C. 1395w-28(f)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Transition and exception regarding restriction on 
     enrollment.--
       ``(A) In general.--Subject to subparagraph (C), the 
     Secretary shall establish procedures for the transition of 
     applicable individuals to--
       ``(i) a Medicare Advantage plan that is not a specialized 
     MA plan for special needs individuals (as defined in 
     subsection (b)(6)); or
       ``(ii) the original medicare fee-for-service program under 
     parts A and B.
       ``(B) Applicable individuals.--For purposes of clause (i), 
     the term `applicable individual' means an individual who--
       ``(i) is enrolled under a specialized MA plan for special 
     needs individuals (as defined in subsection (b)(6)); and
       ``(ii) is not within the 1 or more of the classes of 
     special needs individuals to which enrollment under the plan 
     is restricted to.
       ``(C) Exception.--The Secretary shall provide for an 
     exception to the transition described in subparagraph (A) for 
     a limited period of time for individuals enrolled under a 
     specialized MA plan for special needs individuals described 
     in

[[Page 4294]]

     subsection (b)(6)(B)(ii) who are no longer eligible for 
     medical assistance under title XIX.
       ``(D) Timeline for initial transition.--The Secretary shall 
     ensure that applicable individuals enrolled in a specialized 
     MA plan for special needs individuals (as defined in 
     subsection (b)(6)) prior to January 1, 2010, are transitioned 
     to a plan or the program described in subparagraph (A) by not 
     later than January 1, 2013.''.
       (d) Temporary Extension of Authority To Operate but No 
     Service Area Expansion for Dual Special Needs Plans That Do 
     Not Meet Certain Requirements.--Section 164(c)(2) of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (Public Law 110-275) is amended by striking ``December 31, 
     2010'' and inserting ``December 31, 2012''.
       (e) Authority To Require Special Needs Plans Be NCQA 
     Approved.--Section 1859(f) of the Social Security Act (42 
     U.S.C. 1395w-28(f)), as amended by subsections (a) and (c), 
     is amended--
       (1) in paragraph (2), by adding at the end the following 
     new subparagraph:
       ``(C) If applicable, the plan meets the requirement 
     described in paragraph (7).'';
       (2) in paragraph (3), by adding at the end the following 
     new subparagraph:
       ``(E) If applicable, the plan meets the requirement 
     described in paragraph (7).'';
       (3) in paragraph (4), by adding at the end the following 
     new subparagraph:
       ``(C) If applicable, the plan meets the requirement 
     described in paragraph (7).''; and
       (4) by adding at the end the following new paragraph:
       ``(7) Authority to require special needs plans be ncqa 
     approved.--For 2012 and subsequent years, the Secretary shall 
     require that a Medicare Advantage organization offering a 
     specialized MA plan for special needs individuals be approved 
     by the National Committee for Quality Assurance (based on 
     standards established by the Secretary).''.
       (f) Risk Adjustment.--Section 1853(a)(1)(C) of the Social 
     Security Act (42 U.S.C. 1395i-23(a)(1)(C)) is amended by 
     adding at the end the following new clause:
       ``(iii) Improvements to risk adjustment for special needs 
     individuals with chronic health conditions.--

       ``(I) In general.--For 2011 and subsequent years, for 
     purposes of the adjustment under clause (i) with respect to 
     individuals described in subclause (II), the Secretary shall 
     use a risk score that reflects the known underlying risk 
     profile and chronic health status of similar individuals. 
     Such risk score shall be used instead of the default risk 
     score for new enrollees in Medicare Advantage plans that are 
     not specialized MA plans for special needs individuals (as 
     defined in section 1859(b)(6)).
       ``(II) Individuals described.--An individual described in 
     this subclause is a special needs individual described in 
     subsection (b)(6)(B)(iii) who enrolls in a specialized MA 
     plan for special needs individuals on or after January 1, 
     2011.
       ``(III) Evaluation.--For 2011 and periodically thereafter, 
     the Secretary shall evaluate and revise the risk adjustment 
     system under this subparagraph in order to, as accurately as 
     possible, account for higher medical and care coordination 
     costs associated with frailty, individuals with multiple, 
     comorbid chronic conditions, and individuals with a diagnosis 
     of mental illness, and also to account for costs that may be 
     associated with higher concentrations of beneficiaries with 
     those conditions.
       ``(IV) Publication of evaluation and revisions.--The 
     Secretary shall publish, as part of an announcement under 
     subsection (b), a description of any evaluation conducted 
     under subclause (III) during the preceding year and any 
     revisions made under such subclause as a result of such 
     evaluation.''.

       (g) Technical Correction.--Section 1859(f)(5) of the Social 
     Security Act (42 U.S.C. 1395w-28(f)(5)) is amended, in the 
     matter preceding subparagraph (A), by striking ``described in 
     subsection (b)(6)(B)(i)''.

     SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS.

       Section 1876(h)(5)(C)(ii) of the Social Security Act (42 
     U.S.C. 1395mm(h)(5)(C)(ii)) is amended, in the matter 
     preceding subclause (I), by striking ``January 1, 2010'' and 
     inserting ``January 1, 2013''.

     SEC. 3207. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR-SERVICE 
                   PLANS.

       For plan year 2011 and subsequent plan years, to the extent 
     that the Secretary of Health and Human Services is applying 
     the 2008 service area extension waiver policy (as modified in 
     the April 11, 2008, Centers for Medicare & Medicaid Services' 
     memorandum with the subject ``2009 Employer Group Waiver-
     Modification of the 2008 Service Area Extension Waiver 
     Granted to Certain MA Local Coordinated Care Plans'') to 
     Medicare Advantage coordinated care plans, the Secretary 
     shall extend the application of such waiver policy to 
     employers who contract directly with the Secretary as a 
     Medicare Advantage private fee-for-service plan under section 
     1857(i)(2) of the Social Security Act (42 U.S.C. 1395w-
     27(i)(2)) and that had enrollment as of October 1, 2009.

     SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION 
                   PERMANENT.

       (a) In General.--Section 1859 of the Social Security Act 
     (42 U.S.C. 1395w-28) is amended by adding at the end the 
     following new subsection:
       ``(g) Special Rules for Senior Housing Facility Plans.--
       ``(1) In general.--In the case of a Medicare Advantage 
     senior housing facility plan described in paragraph (2), 
     notwithstanding any other provision of this part to the 
     contrary and in accordance with regulations of the Secretary, 
     the service area of such plan may be limited to a senior 
     housing facility in a geographic area.
       ``(2) Medicare advantage senior housing facility plan 
     described.--For purposes of this subsection, a Medicare 
     Advantage senior housing facility plan is a Medicare 
     Advantage plan that--
       ``(A) restricts enrollment of individuals under this part 
     to individuals who reside in a continuing care retirement 
     community (as defined in section 1852(l)(4)(B));
       ``(B) provides primary care services onsite and has a ratio 
     of accessible physicians to beneficiaries that the Secretary 
     determines is adequate;
       ``(C) provides transportation services for beneficiaries to 
     specialty providers outside of the facility; and
       ``(D) has participated (as of December 31, 2009) in a 
     demonstration project established by the Secretary under 
     which such a plan was offered for not less than 1 year.''.
       (b) Effective Date.--The amendment made by this section 
     shall take effect on January 1, 2010, and shall apply to plan 
     years beginning on or after such date.

     SEC. 3209. AUTHORITY TO DENY PLAN BIDS.

       (a) In General.--Section 1854(a)(5) of the Social Security 
     Act (42 U.S.C. 1395w-24(a)(5)) is amended by adding at the 
     end the following new subparagraph:
       ``(C) Rejection of bids.--
       ``(i) In general.--Nothing in this section shall be 
     construed as requiring the Secretary to accept any or every 
     bid submitted by an MA organization under this subsection.
       ``(ii) Authority to deny bids that propose significant 
     increases in cost sharing or decreases in benefits.--The 
     Secretary may deny a bid submitted by an MA organization for 
     an MA plan if it proposes significant increases in cost 
     sharing or decreases in benefits offered under the plan.''.
       (b) Application Under Part D.--Section 1860D-11(d) of such 
     Act (42 U.S.C. 1395w-111(d)) is amended by adding at the end 
     the following new paragraph:
       ``(3) Rejection of bids.--Paragraph (5)(C) of section 
     1854(a) shall apply with respect to bids submitted by a PDP 
     sponsor under subsection (b) in the same manner as such 
     paragraph applies to bids submitted by an MA organization 
     under such section 1854(a).''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to bids submitted for contract years beginning on 
     or after January 1, 2011.

     SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP 
                   PLANS.

       (a) In General.--Section 1882 of the Social Security Act 
     (42 U.S.C. 1395ss) is amended by adding at the end the 
     following new subsection:
       ``(y) Development of New Standards for Certain Medicare 
     Supplemental Policies.--
       ``(1) In general.--The Secretary shall request the National 
     Association of Insurance Commissioners to review and revise 
     the standards for benefit packages described in paragraph (2) 
     under subsection (p)(1), to otherwise update standards to 
     include requirements for nominal cost sharing to encourage 
     the use of appropriate physicians' services under part B. 
     Such revisions shall be based on evidence published in peer-
     reviewed journals or current examples used by integrated 
     delivery systems and made consistent with the rules 
     applicable under subsection (p)(1)(E) with the reference to 
     the `1991 NAIC Model Regulation' deemed a reference to the 
     NAIC Model Regulation as published in the Federal Register on 
     December 4, 1998, and as subsequently updated by the National 
     Association of Insurance Commissioners to reflect previous 
     changes in law and the reference to `date of enactment of 
     this subsection' deemed a reference to the date of enactment 
     of the Patient Protection and Affordable Care Act. To the 
     extent practicable, such revision shall provide for the 
     implementation of revised standards for benefit packages as 
     of January 1, 2015.
       ``(2) Benefit packages described.--The benefit packages 
     described in this paragraph are benefit packages classified 
     as `C' and `F'.''.
       (b) Conforming Amendment.--Section 1882(o)(1) of the Social 
     Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking 
     ``, and (w)'' and inserting ``(w), and (y)''.

 Subtitle D--Medicare Part D Improvements for Prescription Drug Plans 
                            and MA-PD Plans

     SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM.

       (a) Condition for Coverage of Drugs Under Part D.--Part D 
     of Title XVIII of the Social Security Act (42 U.S.C. 1395w-
     101 et seq.), is amended by adding at the end the following 
     new section:


           ``condition for coverage of drugs under this part

       ``Sec. 1860D-43.  (a) In General.--In order for coverage to 
     be available under this part for covered part D drugs (as 
     defined in section 1860D-2(e)) of a manufacturer, the 
     manufacturer must--
       ``(1) participate in the Medicare coverage gap discount 
     program under section 1860D-14A;
       ``(2) have entered into and have in effect an agreement 
     described in subsection (b) of such section with the 
     Secretary; and
       ``(3) have entered into and have in effect, under terms and 
     conditions specified by the Secretary, a contract with a 
     third party that the Secretary has entered into a contract 
     with under subsection (d)(3) of such section.
       ``(b) Effective Date.--Subsection (a) shall apply to 
     covered part D drugs dispensed under this part on or after 
     July 1, 2010.

[[Page 4295]]

       ``(c) Authorizing Coverage for Drugs Not Covered Under 
     Agreements.--Subsection (a) shall not apply to the dispensing 
     of a covered part D drug if--
       ``(1) the Secretary has made a determination that the 
     availability of the drug is essential to the health of 
     beneficiaries under this part; or
       ``(2) the Secretary determines that in the period beginning 
     on July 1, 2010, and ending on December 31, 2010, there were 
     extenuating circumstances.
       ``(d) Definition of Manufacturer.--In this section, the 
     term `manufacturer' has the meaning given such term in 
     section 1860D-14A(g)(5).''.
       (b) Medicare Coverage Gap Discount Program.--Part D of 
     title XVIII of the Social Security Act (42 U.S.C. 1395w-101) 
     is amended by inserting after section 1860D-14 the following 
     new section:


                ``medicare coverage gap discount program

       ``Sec. 1860D-14A.  (a) Establishment.--The Secretary shall 
     establish a Medicare coverage gap discount program (in this 
     section referred to as the `program') by not later than July 
     1, 2010. Under the program, the Secretary shall enter into 
     agreements described in subsection (b) with manufacturers and 
     provide for the performance of the duties described in 
     subsection (c)(1). The Secretary shall establish a model 
     agreement for use under the program by not later than April 
     1, 2010, in consultation with manufacturers, and allow for 
     comment on such model agreement.
       ``(b) Terms of Agreement.--
       ``(1) In general.--
       ``(A) Agreement.--An agreement under this section shall 
     require the manufacturer to provide applicable beneficiaries 
     access to discounted prices for applicable drugs of the 
     manufacturer.
       ``(B) Provision of discounted prices at the point-of-
     sale.--Except as provided in subsection (c)(1)(A)(iii), such 
     discounted prices shall be provided to the applicable 
     beneficiary at the pharmacy or by the mail order service at 
     the point-of-sale of an applicable drug.
       ``(C) Timing of agreement.--
       ``(i) Special rule for 2010 and 2011.--In order for an 
     agreement with a manufacturer to be in effect under this 
     section with respect to the period beginning on July 1, 2010, 
     and ending on December 31, 2011, the manufacturer shall enter 
     into such agreement not later than May 1, 2010.
       ``(ii) 2012 and subsequent years.--In order for an 
     agreement with a manufacturer to be in effect under this 
     section with respect to plan year 2012 or a subsequent plan 
     year, the manufacturer shall enter into such agreement (or 
     such agreement shall be renewed under paragraph (4)(A)) not 
     later than January 30 of the preceding year.
       ``(2) Provision of appropriate data.--Each manufacturer 
     with an agreement in effect under this section shall collect 
     and have available appropriate data, as determined by the 
     Secretary, to ensure that it can demonstrate to the Secretary 
     compliance with the requirements under the program.
       ``(3) Compliance with requirements for administration of 
     program.--Each manufacturer with an agreement in effect under 
     this section shall comply with requirements imposed by the 
     Secretary or a third party with a contract under subsection 
     (d)(3), as applicable, for purposes of administering the 
     program, including any determination under clause (i) of 
     subsection (c)(1)(A) or procedures established under such 
     subsection (c)(1)(A).
       ``(4) Length of agreement.--
       ``(A) In general.--An agreement under this section shall be 
     effective for an initial period of not less than 18 months 
     and shall be automatically renewed for a period of not less 
     than 1 year unless terminated under subparagraph (B).
       ``(B) Termination.--
       ``(i) By the secretary.--The Secretary may provide for 
     termination of an agreement under this section for a knowing 
     and willful violation of the requirements of the agreement or 
     other good cause shown. Such termination shall not be 
     effective earlier than 30 days after the date of notice to 
     the manufacturer of such termination. The Secretary shall 
     provide, upon request, a manufacturer with a hearing 
     concerning such a termination, and such hearing shall take 
     place prior to the effective date of the termination with 
     sufficient time for such effective date to be repealed if the 
     Secretary determines appropriate.
       ``(ii) By a manufacturer.--A manufacturer may terminate an 
     agreement under this section for any reason. Any such 
     termination shall be effective, with respect to a plan year--

       ``(I) if the termination occurs before January 30 of a plan 
     year, as of the day after the end of the plan year; and
       ``(II) if the termination occurs on or after January 30 of 
     a plan year, as of the day after the end of the succeeding 
     plan year.

       ``(iii) Effectiveness of termination.--Any termination 
     under this subparagraph shall not affect discounts for 
     applicable drugs of the manufacturer that are due under the 
     agreement before the effective date of its termination.
       ``(iv) Notice to third party.--The Secretary shall provide 
     notice of such termination to a third party with a contract 
     under subsection (d)(3) within not less than 30 days before 
     the effective date of such termination.
       ``(c) Duties Described and Special Rule for Supplemental 
     Benefits.--
       ``(1) Duties described.--The duties described in this 
     subsection are the following:
       ``(A) Administration of program.--Administering the 
     program, including--
       ``(i) the determination of the amount of the discounted 
     price of an applicable drug of a manufacturer;
       ``(ii) except as provided in clause (iii), the 
     establishment of procedures under which discounted prices are 
     provided to applicable beneficiaries at pharmacies or by mail 
     order service at the point-of-sale of an applicable drug;
       ``(iii) in the case where, during the period beginning on 
     July 1, 2010, and ending on December 31, 2011, it is not 
     practicable to provide such discounted prices at the point-
     of-sale (as described in clause (ii)), the establishment of 
     procedures to provide such discounted prices as soon as 
     practicable after the point-of-sale;
       ``(iv) the establishment of procedures to ensure that, not 
     later than the applicable number of calendar days after the 
     dispensing of an applicable drug by a pharmacy or mail order 
     service, the pharmacy or mail order service is reimbursed for 
     an amount equal to the difference between--

       ``(I) the negotiated price of the applicable drug; and
       ``(II) the discounted price of the applicable drug;

       ``(v) the establishment of procedures to ensure that the 
     discounted price for an applicable drug under this section is 
     applied before any coverage or financial assistance under 
     other health benefit plans or programs that provide coverage 
     or financial assistance for the purchase or provision of 
     prescription drug coverage on behalf of applicable 
     beneficiaries as the Secretary may specify;
       ``(vi) the establishment of procedures to implement the 
     special rule for supplemental benefits under paragraph (2); 
     and
       ``(vii) providing a reasonable dispute resolution mechanism 
     to resolve disagreements between manufacturers, applicable 
     beneficiaries, and the third party with a contract under 
     subsection (d)(3).
       ``(B) Monitoring compliance.--
       ``(i) In general.--The Secretary shall monitor compliance 
     by a manufacturer with the terms of an agreement under this 
     section.
       ``(ii) Notification.--If a third party with a contract 
     under subsection (d)(3) determines that the manufacturer is 
     not in compliance with such agreement, the third party shall 
     notify the Secretary of such noncompliance for appropriate 
     enforcement under subsection (e).
       ``(C) Collection of data from prescription drug plans and 
     ma-pd plans.--The Secretary may collect appropriate data from 
     prescription drug plans and MA-PD plans in a timeframe that 
     allows for discounted prices to be provided for applicable 
     drugs under this section.
       ``(2) Special rule for supplemental benefits.--For plan 
     year 2010 and each subsequent plan year, in the case where an 
     applicable beneficiary has supplemental benefits with respect 
     to applicable drugs under the prescription drug plan or MA-PD 
     plan that the applicable beneficiary is enrolled in, the 
     applicable beneficiary shall not be provided a discounted 
     price for an applicable drug under this section until after 
     such supplemental benefits have been applied with respect to 
     the applicable drug.
       ``(d) Administration.--
       ``(1) In general.--Subject to paragraph (2), the Secretary 
     shall provide for the implementation of this section, 
     including the performance of the duties described in 
     subsection (c)(1).
       ``(2) Limitation.--
       ``(A) In general.--Subject to subparagraph (B), in 
     providing for such implementation, the Secretary shall not 
     receive or distribute any funds of a manufacturer under the 
     program.
       ``(B) Exception.--The limitation under subparagraph (A) 
     shall not apply to the Secretary with respect to drugs 
     dispensed during the period beginning on July 1, 2010, and 
     ending on December 31, 2010, but only if the Secretary 
     determines that the exception to such limitation under this 
     subparagraph is necessary in order for the Secretary to begin 
     implementation of this section and provide applicable 
     beneficiaries timely access to discounted prices during such 
     period.
       ``(3) Contract with third parties.--The Secretary shall 
     enter into a contract with 1 or more third parties to 
     administer the requirements established by the Secretary in 
     order to carry out this section. At a minimum, the contract 
     with a third party under the preceding sentence shall require 
     that the third party--
       ``(A) receive and transmit information between the 
     Secretary, manufacturers, and other individuals or entities 
     the Secretary determines appropriate;
       ``(B) receive, distribute, or facilitate the distribution 
     of funds of manufacturers to appropriate individuals or 
     entities in order to meet the obligations of manufacturers 
     under agreements under this section;
       ``(C) provide adequate and timely information to 
     manufacturers, consistent with the agreement with the 
     manufacturer under this section, as necessary for the 
     manufacturer to fulfill its obligations under this section; 
     and
       ``(D) permit manufacturers to conduct periodic audits, 
     directly or through contracts, of the data and information 
     used by the third party to determine discounts for applicable 
     drugs of the manufacturer under the program.
       ``(4) Performance requirements.--The Secretary shall 
     establish performance requirements for a third party with a 
     contract under paragraph (3) and safeguards to protect the 
     independence and integrity of the activities carried out by 
     the third party under the program under this section.
       ``(5) Implementation.--The Secretary may implement the 
     program under this section by program instruction or 
     otherwise.

[[Page 4296]]

       ``(6) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to the program under this 
     section.
       ``(e) Enforcement.--
       ``(1) Audits.--Each manufacturer with an agreement in 
     effect under this section shall be subject to periodic audit 
     by the Secretary.
       ``(2) Civil money penalty.--
       ``(A) In general.--The Secretary shall impose a civil money 
     penalty on a manufacturer that fails to provide applicable 
     beneficiaries discounts for applicable drugs of the 
     manufacturer in accordance with such agreement for each such 
     failure in an amount the Secretary determines is commensurate 
     with the sum of--
       ``(i) the amount that the manufacturer would have paid with 
     respect to such discounts under the agreement, which will 
     then be used to pay the discounts which the manufacturer had 
     failed to provide; and
       ``(ii) 25 percent of such amount.
       ``(B) Application.--The provisions of section 1128A (other 
     than subsections (a) and (b)) shall apply to a civil money 
     penalty under this paragraph in the same manner as such 
     provisions apply to a penalty or proceeding under section 
     1128A(a).
       ``(f) Clarification Regarding Availability of Other Covered 
     Part D Drugs.--Nothing in this section shall prevent an 
     applicable beneficiary from purchasing a covered part D drug 
     that is not an applicable drug (including a generic drug or a 
     drug that is not on the formulary of the prescription drug 
     plan or MA-PD plan that the applicable beneficiary is 
     enrolled in).
       ``(g) Definitions.--In this section:
       ``(1) Applicable beneficiary.--The term `applicable 
     beneficiary' means an individual who, on the date of 
     dispensing an applicable drug--
       ``(A) is enrolled in a prescription drug plan or an MA-PD 
     plan;
       ``(B) is not enrolled in a qualified retiree prescription 
     drug plan;
       ``(C) is not entitled to an income-related subsidy under 
     section 1860D-14(a);
       ``(D) is not subject to a reduction in premium subsidy 
     under section 1839(i); and
       ``(E) who--
       ``(i) has reached or exceeded the initial coverage limit 
     under section 1860D-2(b)(3) during the year; and
       ``(ii) has not incurred costs for covered part D drugs in 
     the year equal to the annual out-of-pocket threshold 
     specified in section 1860D-2(b)(4)(B).
       ``(2) Applicable drug.--The term `applicable drug' means, 
     with respect to an applicable beneficiary, a covered part D 
     drug--
       ``(A) approved under a new drug application under section 
     505(b) of the Federal Food, Drug, and Cosmetic Act or, in the 
     case of a biologic product, licensed under section 351 of the 
     Public Health Service Act (other than a product licensed 
     under subsection (k) of such section 351); and
       ``(B)(i) if the PDP sponsor of the prescription drug plan 
     or the MA organization offering the MA-PD plan uses a 
     formulary, which is on the formulary of the prescription drug 
     plan or MA-PD plan that the applicable beneficiary is 
     enrolled in;
       ``(ii) if the PDP sponsor of the prescription drug plan or 
     the MA organization offering the MA-PD plan does not use a 
     formulary, for which benefits are available under the 
     prescription drug plan or MA-PD plan that the applicable 
     beneficiary is enrolled in; or
       ``(iii) is provided through an exception or appeal.
       ``(3) Applicable number of calendar days.--The term 
     `applicable number of calendar days' means--
       ``(A) with respect to claims for reimbursement submitted 
     electronically, 14 days; and
       ``(B) with respect to claims for reimbursement submitted 
     otherwise, 30 days.
       ``(4) Discounted price.--
       ``(A) In general.--The term `discounted price' means 50 
     percent of the negotiated price of the applicable drug of a 
     manufacturer.
       ``(B) Clarification.--Nothing in this section shall be 
     construed as affecting the responsibility of an applicable 
     beneficiary for payment of a dispensing fee for an applicable 
     drug.
       ``(C) Special case for certain claims.--In the case where 
     the entire amount of the negotiated price of an individual 
     claim for an applicable drug with respect to an applicable 
     beneficiary does not fall at or above the initial coverage 
     limit under section 1860D-2(b)(3) and below the annual out-
     of-pocket threshold specified in section 1860D-2(b)(4)(B) for 
     the year, the manufacturer of the applicable drug shall 
     provide the discounted price under this section on only the 
     portion of the negotiated price of the applicable drug that 
     falls at or above such initial coverage limit and below such 
     annual out-of-pocket threshold.
       ``(5) Manufacturer.--The term `manufacturer' means any 
     entity which is engaged in the production, preparation, 
     propagation, compounding, conversion, or processing of 
     prescription drug products, either directly or indirectly by 
     extraction from substances of natural origin, or 
     independently by means of chemical synthesis, or by a 
     combination of extraction and chemical synthesis. Such term 
     does not include a wholesale distributor of drugs or a retail 
     pharmacy licensed under State law.
       ``(6) Negotiated price.--The term `negotiated price' has 
     the meaning given such term in section 423.100 of title 42, 
     Code of Federal Regulations (as in effect on the date of 
     enactment of this section), except that such negotiated price 
     shall not include any dispensing fee for the applicable drug.
       ``(7) Qualified retiree prescription drug plan.--The term 
     `qualified retiree prescription drug plan' has the meaning 
     given such term in section 1860D-22(a)(2).''.
       (c) Inclusion in Incurred Costs.--
       (1) In general.--Section 1860D-2(b)(4) of the Social 
     Security Act (42 U.S.C. 1395w-102(b)(4)) is amended--
       (A) in subparagraph (C), in the matter preceding clause 
     (i), by striking ``In applying'' and inserting ``Except as 
     provided in subparagraph (E), in applying''; and
       (B) by adding at the end the following new subparagraph:
       ``(E) Inclusion of costs of applicable drugs under medicare 
     coverage gap discount program.--In applying subparagraph (A), 
     incurred costs shall include the negotiated price (as defined 
     in paragraph (6) of section 1860D-14A(g)) of an applicable 
     drug (as defined in paragraph (2) of such section) of a 
     manufacturer that is furnished to an applicable beneficiary 
     (as defined in paragraph (1) of such section) under the 
     Medicare coverage gap discount program under section 1860D-
     14A, regardless of whether part of such costs were paid by a 
     manufacturer under such program.''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to costs incurred on or after July 1, 2010.
       (d) Conforming Amendment Permitting Prescription Drug 
     Discounts.--
       (1) In general.--Section 1128B(b)(3) of the Social Security 
     Act (42 U.S.C. 1320a-7b(b)(3)) is amended--
       (A) by striking ``and'' at the end of subparagraph (G);
       (B) in the subparagraph (H) added by section 237(d) of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (Public Law 108-173; 117 Stat. 2213)--
       (i) by moving such subparagraph 2 ems to the left; and
       (ii) by striking the period at the end and inserting a 
     semicolon;
       (C) in the subparagraph (H) added by section 431(a) of such 
     Act (117 Stat. 2287)--
       (i) by redesignating such subparagraph as subparagraph (I);
       (ii) by moving such subparagraph 2 ems to the left; and
       (iii) by striking the period at the end and inserting ``; 
     and''; and
       (D) by adding at the end the following new subparagraph:
       ``(J) a discount in the price of an applicable drug (as 
     defined in paragraph (2) of section 1860D-14A(g)) of a 
     manufacturer that is furnished to an applicable beneficiary 
     (as defined in paragraph (1) of such section) under the 
     Medicare coverage gap discount program under section 1860D-
     14A.''.
       (2) Conforming amendment to definition of best price under 
     medicaid.--Section 1927(c)(1)(C)(i)(VI) of the Social 
     Security Act (42 U.S.C. 1396r-8(c)(1)(C)(i)(VI)) is amended 
     by inserting ``, or any discounts provided by manufacturers 
     under the Medicare coverage gap discount program under 
     section 1860D-14A'' before the period at the end.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to drugs dispensed on or after July 1, 2010.

     SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART D 
                   LOW-INCOME BENCHMARK PREMIUM.

       (a) In General.--Section 1860D-14(b)(2)(B)(iii) of the 
     Social Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is 
     amended by inserting ``, determined without regard to any 
     reduction in such premium as a result of any beneficiary 
     rebate under section 1854(b)(1)(C) or bonus payment under 
     section 1853(n)'' before the period at the end.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to premiums for months beginning on or after 
     January 1, 2011.

     SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE 
                   INDIVIDUALS UNDER PRESCRIPTION DRUG PLANS AND 
                   MA-PD PLANS.

       (a) In General.--Section 1860D-14(a) of the Social Security 
     Act (42 U.S.C. 1395w-114(a)) is amended by adding at the end 
     the following new paragraph:
       ``(5) Waiver of de minimis premiums.--The Secretary shall, 
     under procedures established by the Secretary, permit a 
     prescription drug plan or an MA-PD plan to waive the monthly 
     beneficiary premium for a subsidy eligible individual if the 
     amount of such premium is de minimis. If such premium is 
     waived under the plan, the Secretary shall not reassign 
     subsidy eligible individuals enrolled in the plan to other 
     plans based on the fact that the monthly beneficiary premium 
     under the plan was greater than the low-income benchmark 
     premium amount.''.
       (b) Authorizing the Secretary To Auto-enroll Subsidy 
     Eligible Individuals in Plans That Waive De Minimis 
     Premiums.--Section 1860D-1(b)(1) of the Social Security Act 
     (42 U.S.C. 1395w-101(b)(1)) is amended--
       (1) in subparagraph (C), by inserting ``except as provided 
     in subparagraph (D),'' after ``shall include,''
       (2) by adding at the end the following new subparagraph:
       ``(D) Special rule for plans that waive de minimis 
     premiums.--The process established under subparagraph (A) may 
     include, in the case of a part D eligible individual who is a 
     subsidy eligible individual (as defined in section 1860D-
     14(a)(3)) who has failed to enroll in a prescription drug 
     plan or an MA-PD plan, for the enrollment in a prescription 
     drug plan or MA-PD plan that has waived the monthly 
     beneficiary premium for such subsidy eligible individual 
     under section 1860D-14(a)(5). If there is

[[Page 4297]]

     more than one such plan available, the Secretary shall enroll 
     such an individual under the preceding sentence on a random 
     basis among all such plans in the PDP region. Nothing in the 
     previous sentence shall prevent such an individual from 
     declining or changing such enrollment.''.
       (c) Effective Date.--The amendments made by this subsection 
     shall apply to premiums for months, and enrollments for plan 
     years, beginning on or after January 1, 2011.

     SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING 
                   ELIGIBILITY FOR LOW-INCOME ASSISTANCE.

       (a) In General.--Section 1860D-14(a)(3)(B) of the Social 
     Security Act (42 U.S.C. 1395w-114(a)(3)(B)) is amended by 
     adding at the end the following new clause:
       ``(vi) Special rule for widows and widowers.--
     Notwithstanding the preceding provisions of this 
     subparagraph, in the case of an individual whose spouse dies 
     during the effective period for a determination or 
     redetermination that has been made under this subparagraph, 
     such effective period shall be extended through the date that 
     is 1 year after the date on which the determination or 
     redetermination would (but for the application of this 
     clause) otherwise cease to be effective.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on January 1, 2011.

     SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE 
                   INDIVIDUALS REASSIGNED TO PRESCRIPTION DRUG 
                   PLANS AND MA-PD PLANS.

       Section 1860D-14 of the Social Security Act (42 U.S.C. 
     1395w-114) is amended--
       (1) by redesignating subsection (d) as subsection (e); and
       (2) by inserting after subsection (c) the following new 
     subsection:
       ``(d) Facilitation of Reassignments.--Beginning not later 
     than January 1, 2011, the Secretary shall, in the case of a 
     subsidy eligible individual who is enrolled in one 
     prescription drug plan and is subsequently reassigned by the 
     Secretary to a new prescription drug plan, provide the 
     individual, within 30 days of such reassignment, with--
       ``(1) information on formulary differences between the 
     individual's former plan and the plan to which the individual 
     is reassigned with respect to the individual's drug regimens; 
     and
       ``(2) a description of the individual's right to request a 
     coverage determination, exception, or reconsideration under 
     section 1860D-4(g), bring an appeal under section 1860D-4(h), 
     or resolve a grievance under section 1860D-4(f).''.

     SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME 
                   PROGRAMS.

       (a) Additional Funding for State Health Insurance 
     Programs.--Subsection (a)(1)(B) of section 119 of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (42 U.S.C. 1395b-3 note) is amended by striking ``(42 U.S.C. 
     1395w-23(f))'' and all that follows through the period at the 
     end and inserting ``(42 U.S.C. 1395w-23(f)), to the Centers 
     for Medicare & Medicaid Services Program Management Account--
       ``(i) for fiscal year 2009, of $7,500,000; and
       ``(ii) for the period of fiscal years 2010 through 2012, of 
     $15,000,000.

     Amounts appropriated under this subparagraph shall remain 
     available until expended.''.
       (b) Additional Funding for Area Agencies on Aging.--
     Subsection (b)(1)(B) of such section 119 is amended by 
     striking ``(42 U.S.C. 1395w-23(f))'' and all that follows 
     through the period at the end and inserting ``(42 U.S.C. 
     1395w-23(f)), to the Administration on Aging--
       ``(i) for fiscal year 2009, of $7,500,000; and
       ``(ii) for the period of fiscal years 2010 through 2012, of 
     $15,000,000.
     Amounts appropriated under this subparagraph shall remain 
     available until expended.''.
       (c) Additional Funding for Aging and Disability Resource 
     Centers.--Subsection (c)(1)(B) of such section 119 is amended 
     by striking ``(42 U.S.C. 1395w-23(f))'' and all that follows 
     through the period at the end and inserting ``(42 U.S.C. 
     1395w-23(f)), to the Administration on Aging--
       ``(i) for fiscal year 2009, of $5,000,000; and
       ``(ii) for the period of fiscal years 2010 through 2012, of 
     $10,000,000.
     Amounts appropriated under this subparagraph shall remain 
     available until expended.''.
       (d) Additional Funding for Contract With the National 
     Center for Benefits and Outreach Enrollment.--Subsection 
     (d)(2) of such section 119 is amended by striking ``(42 
     U.S.C. 1395w-23(f))'' and all that follows through the period 
     at the end and inserting ``(42 U.S.C. 1395w-23(f)), to the 
     Administration on Aging--
       ``(i) for fiscal year 2009, of $5,000,000; and
       ``(ii) for the period of fiscal years 2010 through 2012, of 
     $5,000,000.
     Amounts appropriated under this subparagraph shall remain 
     available until expended.''.
       (e) Secretarial Authority To Enlist Support in Conducting 
     Certain Outreach Activities.--Such section 119 is amended by 
     adding at the end the following new subsection:
       ``(g) Secretarial Authority To Enlist Support in Conducting 
     Certain Outreach Activities.--The Secretary may request that 
     an entity awarded a grant under this section support the 
     conduct of outreach activities aimed at preventing disease 
     and promoting wellness. Notwithstanding any other provision 
     of this section, an entity may use a grant awarded under this 
     subsection to support the conduct of activities described in 
     the preceding sentence.''.

     SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIPTION 
                   DRUG PLANS AND MA-PD PLANS WITH RESPECT TO 
                   CERTAIN CATEGORIES OR CLASSES OF DRUGS.

       (a) Improving Formulary Requirements.--Section 1860D-
     4(b)(3)(G) of the Social Security Act is amended to read as 
     follows:
       ``(G) Required inclusion of drugs in certain categories and 
     classes.--
       ``(i) Formulary requirements.--

       ``(I) In general.--Subject to subclause (II), a PDP sponsor 
     offering a prescription drug plan shall be required to 
     include all covered part D drugs in the categories and 
     classes identified by the Secretary under clause (ii)(I).
       ``(II) Exceptions.--The Secretary may establish exceptions 
     that permit a PDP sponsor offering a prescription drug plan 
     to exclude from its formulary a particular covered part D 
     drug in a category or class that is otherwise required to be 
     included in the formulary under subclause (I) (or to 
     otherwise limit access to such a drug, including through 
     prior authorization or utilization management).

       ``(ii) Identification of drugs in certain categories and 
     classes.--

       ``(I) In general.--Subject to clause (iv), the Secretary 
     shall identify, as appropriate, categories and classes of 
     drugs for which the Secretary determines are of clinical 
     concern.
       ``(II) Criteria.--The Secretary shall use criteria 
     established by the Secretary in making any determination 
     under subclause (I).

       ``(iii) Implementation.--The Secretary shall establish the 
     criteria under clause (ii)(II) and any exceptions under 
     clause (i)(II) through the promulgation of a regulation which 
     includes a public notice and comment period.
       ``(iv) Requirement for certain categories and classes until 
     criteria established.--Until such time as the Secretary 
     establishes the criteria under clause (ii)(II) the following 
     categories and classes of drugs shall be identified under 
     clause (ii)(I):

       ``(I) Anticonvulsants.
       ``(II) Antidepressants.
       ``(III) Antineoplastics.
       ``(IV) Antipsychotics.
       ``(V) Antiretrovirals.
       ``(VI) Immunosuppressants for the treatment of transplant 
     rejection.''.

       (b) Effective Date.--The amendments made by this section 
     shall apply to plan year 2011 and subsequent plan years.

     SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME 
                   BENEFICIARIES.

       (a) Income-Related Increase in Part D Premium.--
       (1) In general.--Section 1860D-13(a) of the Social Security 
     Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end 
     the following new paragraph:
       ``(7) Increase in base beneficiary premium based on 
     income.--
       ``(A) In general.--In the case of an individual whose 
     modified adjusted gross income exceeds the threshold amount 
     applicable under paragraph (2) of section 1839(i) (including 
     application of paragraph (5) of such section) for the 
     calendar year, the monthly amount of the beneficiary premium 
     applicable under this section for a month after December 2010 
     shall be increased by the monthly adjustment amount specified 
     in subparagraph (B).
       ``(B) Monthly adjustment amount.--The monthly adjustment 
     amount specified in this subparagraph for an individual for a 
     month in a year is equal to the product of--
       ``(i) the quotient obtained by dividing--

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

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

       ``(I) The modified adjusted gross income threshold 
     applicable under paragraph (2) of section 1839(i) (including 
     application of paragraph (5) of such section).
       ``(II) The applicable percentage determined under paragraph 
     (3)(C) of section 1839(i) (including application of paragraph 
     (5) of such section).
       ``(III) The monthly adjustment amount specified in 
     subparagraph (B).

[[Page 4298]]

       ``(IV) Any other information the Commissioner of Social 
     Security determines necessary to carry out the income-related 
     increase in the base beneficiary premium under this 
     paragraph.

       ``(F) Rule of construction.--The formula used to determine 
     the monthly adjustment amount specified under subparagraph 
     (B) shall only be used for the purpose of determining such 
     monthly adjustment amount under such subparagraph.''.
       (2) Collection of monthly adjustment amount.--Section 
     1860D-13(c) of the Social Security Act (42 U.S.C. 1395w-
     113(c)) is amended--
       (A) in paragraph (1), by striking ``(2) and (3)'' and 
     inserting ``(2), (3), and (4)''; and
       (B) by adding at the end the following new paragraph:
       ``(4) Collection of monthly adjustment amount.--
       ``(A) In general.--Notwithstanding any provision of this 
     subsection or section 1854(d)(2), subject to subparagraph 
     (B), the amount of the income-related increase in the base 
     beneficiary premium for an individual for a month (as 
     determined under subsection (a)(7)) shall be paid through 
     withholding from benefit payments in the manner provided 
     under section 1840.
       ``(B) Agreements.--In the case where the monthly benefit 
     payments of an individual that are withheld under 
     subparagraph (A) are insufficient to pay the amount described 
     in such subparagraph, the Commissioner of Social Security 
     shall enter into agreements with the Secretary, the Director 
     of the Office of Personnel Management, and the Railroad 
     Retirement Board as necessary in order to allow other 
     agencies to collect the amount described in subparagraph (A) 
     that was not withheld under such subparagraph.''.
       (b) Conforming Amendments.--
       (1) Medicare.--Section 1860D-13(a)(1) of the Social 
     Security Act (42 U.S.C. 1395w-113(a)(1)) is amended--
       (A) by redesignating subparagraph (F) as subparagraph (G);
       (B) in subparagraph (G), as redesignated by subparagraph 
     (A), by striking ``(D) and (E)'' and inserting ``(D), (E), 
     and (F)''; and
       (C) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) Increase based on income.--The monthly beneficiary 
     premium shall be increased pursuant to paragraph (7).''.
       (2) Internal revenue code.--Section 6103(l)(20) of the 
     Internal Revenue Code of 1986 (relating to disclosure of 
     return information to carry out Medicare part B premium 
     subsidy adjustment) is amended--
       (A) in the heading, by inserting ``and part d base 
     beneficiary premium increase'' after ``part b premium subsidy 
     adjustment'';
       (B) in subparagraph (A)--
       (i) in the matter preceding clause (i), by inserting ``or 
     increase under section 1860D-13(a)(7)'' after ``1839(i)''; 
     and
       (ii) in clause (vii), by inserting after ``subsection (i) 
     of such section'' the following: ``or increase under section 
     1860D-13(a)(7) of such Act''; and
       (C) in subparagraph (B)--
       (i) by striking ``Return information'' and inserting the 
     following:
       ``(i) In general.--Return information'';
       (ii) by inserting ``or increase under such section 1860D-
     13(a)(7)'' before the period at the end;
       (iii) as amended by clause (i), by inserting ``or for the 
     purpose of resolving taxpayer appeals with respect to any 
     such premium adjustment or increase'' before the period at 
     the end; and
       (iv) by adding at the end the following new clause:
       ``(ii) Disclosure to other agencies.--Officers, employees, 
     and contractors of the Social Security Administration may 
     disclose--

       ``(I) the taxpayer identity information and the amount of 
     the premium subsidy adjustment or premium increase with 
     respect to a taxpayer described in subparagraph (A) to 
     officers, employees, and contractors of the Centers for 
     Medicare and Medicaid Services, to the extent that such 
     disclosure is necessary for the collection of the premium 
     subsidy amount or the increased premium amount,
       ``(II) the taxpayer identity information and the amount of 
     the premium subsidy adjustment or the increased premium 
     amount with respect to a taxpayer described in subparagraph 
     (A) to officers and employees of the Office of Personnel 
     Management and the Railroad Retirement Board, to the extent 
     that such disclosure is necessary for the collection of the 
     premium subsidy amount or the increased premium amount,
       ``(III) return information with respect to a taxpayer 
     described in subparagraph (A) to officers and employees of 
     the Department of Health and Human Services to the extent 
     necessary to resolve administrative appeals of such premium 
     subsidy adjustment or increased premium, and
       ``(IV) return information with respect to a taxpayer 
     described in subparagraph (A) to officers and employees of 
     the Department of Justice for use in judicial proceedings to 
     the extent necessary to carry out the purposes described in 
     clause (i).''.

     SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL 
                   ELIGIBLE INDIVIDUALS.

       Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 
     U.S.C. 1395w-114(a)(1)(D)(i)) is amended by inserting ``or, 
     effective on a date specified by the Secretary (but in no 
     case earlier than January 1, 2012), who would be such an 
     institutionalized individual or couple, if the full-benefit 
     dual eligible individual were not receiving services under a 
     home and community-based waiver authorized for a State under 
     section 1115 or subsection (c) or (d) of section 1915 or 
     under a State plan amendment under subsection (i) of such 
     section or services provided through enrollment in a medicaid 
     managed care organization with a contract under section 
     1903(m) or under section 1932'' after ``1902(q)(1)(B))''.

     SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT 
                   PRESCRIPTION DRUGS IN LONG-TERM CARE FACILITIES 
                   UNDER PRESCRIPTION DRUG PLANS AND MA-PD PLANS.

       (a) In General.--Section 1860D-4(c) of the Social Security 
     Act (42 U.S.C. 1395w-104(c)) is amended by adding at the end 
     the following new paragraph:
       ``(3) Reducing wasteful dispensing of outpatient 
     prescription drugs in long-term care facilities.--The 
     Secretary shall require PDP sponsors of prescription drug 
     plans to utilize specific, uniform dispensing techniques, as 
     determined by the Secretary, in consultation with relevant 
     stakeholders (including representatives of nursing 
     facilities, residents of nursing facilities, pharmacists, the 
     pharmacy industry (including retail and long-term care 
     pharmacy), prescription drug plans, MA-PD plans, and any 
     other stakeholders the Secretary determines appropriate), 
     such as weekly, daily, or automated dose dispensing, when 
     dispensing covered part D drugs to enrollees who reside in a 
     long-term care facility in order to reduce waste associated 
     with 30-day fills.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to plan years beginning on or after January 1, 
     2012.

     SEC. 3311. IMPROVED MEDICARE PRESCRIPTION DRUG PLAN AND MA-PD 
                   PLAN COMPLAINT SYSTEM.

       (a) In General.--The Secretary shall develop and maintain a 
     complaint system, that is widely known and easy to use, to 
     collect and maintain information on MA-PD plan and 
     prescription drug plan complaints that are received 
     (including by telephone, letter, e-mail, or any other means) 
     by the Secretary (including by a regional office of the 
     Department of Health and Human Services, the Medicare 
     Beneficiary Ombudsman, a subcontractor, a carrier, a fiscal 
     intermediary, and a Medicare administrative contractor under 
     section 1874A of the Social Security Act (42 U.S.C. 1395kk)) 
     through the date on which the complaint is resolved. The 
     system shall be able to report and initiate appropriate 
     interventions and monitoring based on substantial complaints 
     and to guide quality improvement.
       (b) Model Electronic Complaint Form.--The Secretary shall 
     develop a model electronic complaint form to be used for 
     reporting plan complaints under the system. Such form shall 
     be prominently displayed on the front page of the 
     Medicare.gov Internet website and on the Internet website of 
     the Medicare Beneficiary Ombudsman.
       (c) Annual Reports by the Secretary.--The Secretary shall 
     submit to Congress annual reports on the system. Such reports 
     shall include an analysis of the number and types of 
     complaints reported in the system, geographic variations in 
     such complaints, the timeliness of agency or plan responses 
     to such complaints, and the resolution of such complaints.
       (d) Definitions.--In this section:
       (1) MA-PD plan.--The term ``MA-PD plan'' has the meaning 
     given such term in section 1860D-41(a)(9) of such Act (42 
     U.S.C. 1395w-151(a)(9)).
       (2) Prescription drug plan.--The term ``prescription drug 
     plan'' has the meaning given such term in section 1860D-
     41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)).
       (3) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (4) System.--The term ``system'' means the plan complaint 
     system developed and maintained under subsection (a).

     SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR 
                   PRESCRIPTION DRUG PLANS AND MA-PD PLANS.

       (a) In General.--Section 1860D-4(b)(3) of the Social 
     Security Act (42 U.S.C. 1395w-104(b)(3)) is amended by adding 
     at the end the following new subparagraph:
       ``(H) Use of single, uniform exceptions and appeals 
     process.--Notwithstanding any other provision of this part, 
     each PDP sponsor of a prescription drug plan shall--
       ``(i) use a single, uniform exceptions and appeals process 
     (including, to the extent the Secretary determines feasible, 
     a single, uniform model form for use under such process) with 
     respect to the determination of prescription drug coverage 
     for an enrollee under the plan; and
       ``(ii) provide instant access to such process by enrollees 
     through a toll-free telephone number and an Internet 
     website.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to exceptions and appeals on or after January 1, 
     2012.

     SEC. 3313. OFFICE OF THE INSPECTOR GENERAL STUDIES AND 
                   REPORTS.

       (a) Study and Annual Report on Part D Formularies' 
     Inclusion of Drugs Commonly Used by Dual Eligibles.--
       (1) Study.--The Inspector General of the Department of 
     Health and Human Services shall conduct a study of the extent 
     to which formularies used by prescription drug plans and MA-
     PD plans under part D include drugs commonly used by full-
     benefit dual eligible individuals (as defined in section 
     1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
     5(c)(6))).
       (2) Annual reports.--Not later than July 1 of each year 
     (beginning with 2011), the Inspector General shall submit to 
     Congress a report on the study conducted under paragraph (1), 
     together

[[Page 4299]]

     with such recommendations as the Inspector General determines 
     appropriate.
       (b) Study and Report on Prescription Drug Prices Under 
     Medicare Part D and Medicaid.--
       (1) Study.--
       (A) In general.--The Inspector General of the Department of 
     Health and Human Services shall conduct a study on prices for 
     covered part D drugs under the Medicare prescription drug 
     program under part D of title XVIII of the Social Security 
     Act and for covered outpatient drugs under title XIX. Such 
     study shall include the following:
       (i) A comparison, with respect to the 200 most frequently 
     dispensed covered part D drugs under such program and covered 
     outpatient drugs under such title (as determined by the 
     Inspector General based on volume and expenditures), of--

       (I) the prices paid for covered part D drugs by PDP 
     sponsors of prescription drug plans and Medicare Advantage 
     organizations offering MA-PD plans; and
       (II) the prices paid for covered outpatient drugs by a 
     State plan under title XIX.

       (ii) An assessment of--

       (I) the financial impact of any discrepancies in such 
     prices on the Federal Government; and
       (II) the financial impact of any such discrepancies on 
     enrollees under part D or individuals eligible for medical 
     assistance under a State plan under title XIX.

       (B) Price.--For purposes of subparagraph (A), the price of 
     a covered part D drug or a covered outpatient drug shall 
     include any rebate or discount under such program or such 
     title, respectively, including any negotiated price 
     concession described in section 1860D-2(d)(1)(B) of the 
     Social Security Act (42 U.S.C. 1395w-102(d)(1)(B)) or rebate 
     under an agreement under section 1927 of the Social Security 
     Act (42 U.S.C. 1396r-8).
       (C) Authority to collect any necessary information.--
     Notwithstanding any other provision of law, the Inspector 
     General of the Department of Health and Human Services shall 
     be able to collect any information related to the prices of 
     covered part D drugs under such program and covered 
     outpatient drugs under such title XIX necessary to carry out 
     the comparison under subparagraph (A).
       (2) Report.--
       (A) In general.--Not later than October 1, 2011, subject to 
     subparagraph (B), the Inspector General shall submit to 
     Congress a report containing the results of the study 
     conducted under paragraph (1), together with recommendations 
     for such legislation and administrative action as the 
     Inspector General determines appropriate.
       (B) Limitation on information contained in report.--The 
     report submitted under subparagraph (A) shall not include any 
     information that the Inspector General determines is 
     proprietary or is likely to negatively impact the ability of 
     a PDP sponsor or a State plan under title XIX to negotiate 
     prices for covered part D drugs or covered outpatient drugs, 
     respectively.
       (3) Definitions.--In this section:
       (A) Covered part d drug.--The term ``covered part D drug'' 
     has the meaning given such term in section 1860D-2(e) of the 
     Social Security Act (42 U.S.C. 1395w-102(e)).
       (B) Covered outpatient drug.--The term ``covered outpatient 
     drug'' has the meaning given such term in section 1927(k) of 
     such Act (42 U.S.C. 1396r(k)).
       (C) MA-PD plan.--The term ``MA-PD plan'' has the meaning 
     given such term in section 1860D-41(a)(9) of such Act (42 
     U.S.C. 1395w-151(a)(9)).
       (D) Medicare advantage organization.--The term ``Medicare 
     Advantage organization'' has the meaning given such term in 
     section 1859(a)(1) of such Act (42 U.S.C. 1395w-28)(a)(1)).
       (E) PDP sponsor.--The term ``PDP sponsor'' has the meaning 
     given such term in section 1860D-41(a)(13) of such Act (42 
     U.S.C. 1395w-151(a)(13)).
       (F) Prescription drug plan.--The term ``prescription drug 
     plan'' has the meaning given such term in section 1860D-
     41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)).

     SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE 
                   PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING 
                   PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF-
                   POCKET THRESHOLD UNDER PART D.

       (a) In General.--Section 1860D-2(b)(4)(C) of the Social 
     Security Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) in clause (ii)--
       (A) by striking ``such costs shall be treated as incurred 
     only if'' and inserting ``subject to clause (iii), such costs 
     shall be treated as incurred only if'';
       (B) by striking ``, under section 1860D-14, or under a 
     State Pharmaceutical Assistance Program''; and
       (C) by striking the period at the end and inserting ``; 
     and''; and
       (3) by inserting after clause (ii) the following new 
     clause:
       ``(iii) such costs shall be treated as incurred and shall 
     not be considered to be reimbursed under clause (ii) if such 
     costs are borne or paid--

       ``(I) under section 1860D-14;
       ``(II) under a State Pharmaceutical Assistance Program;
       ``(III) by the Indian Health Service, an Indian tribe or 
     tribal organization, or an urban Indian organization (as 
     defined in section 4 of the Indian Health Care Improvement 
     Act); or
       ``(IV) under an AIDS Drug Assistance Program under part B 
     of title XXVI of the Public Health Service Act.''.

       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to costs incurred on or after January 1, 2011.

     SEC. 3315. IMMEDIATE REDUCTION IN COVERAGE GAP IN 2010.

       Section 1860D-2(b) of the Social Security Act (42 U.S.C. 
     1395w-102(b)) is amended--
       (1) in paragraph (3)(A), by striking ``paragraph (4)'' and 
     inserting ``paragraphs (4) and (7)''; and
       (2) by adding at the end the following new paragraph:
       ``(7) Increase in initial coverage limit in 2010.--
       ``(A) In general.--For the plan year beginning on January 
     1, 2010, the initial coverage limit described in paragraph 
     (3)(B) otherwise applicable shall be increased by $500.
       ``(B) Application.--In applying subparagraph (A)--
       ``(i) except as otherwise provided in this subparagraph, 
     there shall be no change in the premiums, bids, or any other 
     parameters under this part or part C;
       ``(ii) costs that would be treated as incurred costs for 
     purposes of applying paragraph (4) but for the application of 
     subparagraph (A) shall continue to be treated as incurred 
     costs;
       ``(iii) the Secretary shall establish procedures, which may 
     include a reconciliation process, to fully reimburse PDP 
     sponsors with respect to prescription drug plans and MA 
     organizations with respect to MA-PD plans for the reduction 
     in beneficiary cost sharing associated with the application 
     of subparagraph (A);
       ``(iv) the Secretary shall develop an estimate of the 
     additional increased costs attributable to the application of 
     this paragraph for increased drug utilization and financing 
     and administrative costs and shall use such estimate to 
     adjust payments to PDP sponsors with respect to prescription 
     drug plans under this part and MA organizations with respect 
     to MA-PD plans under part C; and
       ``(v) the Secretary shall establish procedures for 
     retroactive reimbursement of part D eligible individuals who 
     are covered under such a plan for costs which are incurred 
     before the date of initial implementation of subparagraph (A) 
     and which would be reimbursed under such a plan if such 
     implementation occurred as of January 1, 2010.
       ``(C) No effect on subsequent years.--The increase under 
     subparagraph (A) shall only apply with respect to the plan 
     year beginning on January 1, 2010, and the initial coverage 
     limit for plan years beginning on or after January 1, 2011, 
     shall be determined as if subparagraph (A) had never 
     applied.''.

              Subtitle E--Ensuring Medicare Sustainability

     SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND 
                   INCORPORATION OF PRODUCTIVITY IMPROVEMENTS INTO 
                   MARKET BASKET UPDATES THAT DO NOT ALREADY 
                   INCORPORATE SUCH IMPROVEMENTS.

       (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of 
     the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as 
     amended by section 3001(a)(3), is further amended--
       (1) in clause (i)(XX), by striking ``clause (viii)'' and 
     inserting ``clauses (viii), (ix), (xi), and (xii)'';
       (2) in the first sentence of clause (viii), by inserting 
     ``of such applicable percentage increase (determined without 
     regard to clause (ix), (xi), or (xii))'' after ``one-
     quarter'';
       (3) in the first sentence of clause (ix)(I), by inserting 
     ``(determined without regard to clause (viii), (xi), or 
     (xii))'' after ``clause (i)'' the second time it appears; and
       (4) by adding at the end the following new clauses:
       ``(xi)(I) For 2012 and each subsequent fiscal year, after 
     determining the applicable percentage increase described in 
     clause (i) and after application of clauses (viii) and (ix), 
     such percentage increase shall be reduced by the productivity 
     adjustment described in subclause (II).
       ``(II) The productivity adjustment described in this 
     subclause, with respect to a percentage, factor, or update 
     for a fiscal year, year, cost reporting period, or other 
     annual period, is a productivity adjustment equal to the 10-
     year moving average of changes in annual economy-wide private 
     nonfarm business multi-factor productivity (as projected by 
     the Secretary for the 10-year period ending with the 
     applicable fiscal year, year, cost reporting period, or other 
     annual period).
       ``(III) The application of subclause (I) may result in the 
     applicable percentage increase described in clause (i) being 
     less than 0.0 for a fiscal year, and may result in payment 
     rates under this section for a fiscal year being less than 
     such payment rates for the preceding fiscal year.
       ``(xii) After determining the applicable percentage 
     increase described in clause (i), and after application of 
     clauses (viii), (ix), and (xi), the Secretary shall reduce 
     such applicable percentage increase--
       ``(I) for each of fiscal years 2010 and 2011, by 0.25 
     percentage point; and
       ``(II) subject to clause (xiii), for each of fiscal years 
     2012 through 2019, by 0.2 percentage point.

     The application of this clause may result in the applicable 
     percentage increase described in clause (i) being less than 
     0.0 for a fiscal year, and may result in payment rates under 
     this section for a fiscal year being less than such payment 
     rates for the preceding fiscal year.
       ``(xiii) Clause (xii) shall be applied with respect to any 
     of fiscal years 2014 through 2019 by

[[Page 4300]]

     substituting `0.0 percentage points' for `0.2 percentage 
     point', if for such fiscal year--
       ``(I) the excess (if any) of--
       ``(aa) the total percentage of the non-elderly insured 
     population for the preceding fiscal year (based on the most 
     recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     the Patient Protection and Affordable Care Act that, if 
     determined in the affirmative, would clear such Act for 
     enrollment); over
       ``(bb) the total percentage of the non-elderly insured 
     population for such preceding fiscal year (as estimated by 
     the Secretary); exceeds
       ``(II) 5 percentage points.''.
       (b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of 
     the Social Security Act (42 U.S.C. 1395yy(e)(5)(B)) is 
     amended--
       (1) by striking ``percentage.--The term'' and inserting 
     ``percentage.--
       ``(i) In general.--Subject to clause (ii), the term''; and
       (2) by adding at the end the following new clause:
       ``(ii) Adjustment.--For fiscal year 2012 and each 
     subsequent fiscal year, after determining the percentage 
     described in clause (i), the Secretary shall reduce such 
     percentage by the productivity adjustment described in 
     section 1886(b)(3)(B)(xi)(II). The application of the 
     preceding sentence may result in such percentage being less 
     than 0.0 for a fiscal year, and may result in payment rates 
     under this subsection for a fiscal year being less than such 
     payment rates for the preceding fiscal year.''.
       (c) Long-term Care Hospitals.--Section 1886(m) of the 
     Social Security Act (42 U.S.C. 1395ww(m)) is amended by 
     adding at the end the following new paragraphs:
       ``(3) Implementation for rate year 2010 and subsequent 
     years.--
       ``(A) In general.--In implementing the system described in 
     paragraph (1) for rate year 2010 and each subsequent rate 
     year, any annual update to a standard Federal rate for 
     discharges for the hospital during the rate year, shall be 
     reduced--
       ``(i) for rate year 2012 and each subsequent rate year, by 
     the productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II); and
       ``(ii) for each of rate years 2010 through 2019, by the 
     other adjustment described in paragraph (4).
       ``(B) Special rule.--The application of this paragraph may 
     result in such annual update being less than 0.0 for a rate 
     year, and may result in payment rates under the system 
     described in paragraph (1) for a rate year being less than 
     such payment rates for the preceding rate year.
       ``(4) Other adjustment.--
       ``(A) In general.--For purposes of paragraph (3)(A)(ii), 
     the other adjustment described in this paragraph is--
       ``(i) for each of rate years 2010 and 2011, 0.25 percentage 
     point; and
       ``(ii) subject to subparagraph (B), for each of rate years 
     2012 through 2019, 0.2 percentage point.
       ``(B) Reduction of other adjustment.--Subparagraph (A)(ii) 
     shall be applied with respect to any of rate years 2014 
     through 2019 by substituting `0.0 percentage points' for `0.2 
     percentage point', if for such rate year--
       ``(i) the excess (if any) of--

       ``(I) the total percentage of the non-elderly insured 
     population for the preceding rate year (based on the most 
     recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     the Patient Protection and Affordable Care Act that, if 
     determined in the affirmative, would clear such Act for 
     enrollment); over
       ``(II) the total percentage of the non-elderly insured 
     population for such preceding rate year (as estimated by the 
     Secretary); exceeds

       ``(ii) 5 percentage points.''.
       (d) Inpatient Rehabilitation Facilities.--Section 
     1886(j)(3) of the Social Security Act (42 U.S.C. 
     1395ww(j)(3)) is amended--
       (1) in subparagraph (C)--
       (A) by striking ``factor.--For purposes'' and inserting 
     ``factor.--
       ``(i) In general.--For purposes'';
       (B) by inserting ``subject to clause (ii)'' before the 
     period at the end of the first sentence of clause (i), as 
     added by paragraph (1); and
       (C) by adding at the end the following new clause:
       ``(ii) Productivity and other adjustment.--After 
     establishing the increase factor described in clause (i) for 
     a fiscal year, the Secretary shall reduce such increase 
     factor--

       ``(I) for fiscal year 2012 and each subsequent fiscal year, 
     by the productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II); and
       ``(II) for each of fiscal years 2010 through 2019, by the 
     other adjustment described in subparagraph (D).

     The application of this clause may result in the increase 
     factor under this subparagraph being less than 0.0 for a 
     fiscal year, and may result in payment rates under this 
     subsection for a fiscal year being less than such payment 
     rates for the preceding fiscal year.''; and
       (2) by adding at the end the following new subparagraph:
       ``(D) Other adjustment.--
       ``(i) In general.--For purposes of subparagraph 
     (C)(ii)(II), the other adjustment described in this 
     subparagraph is--

       ``(I) for each of fiscal years 2010 and 2011, 0.25 
     percentage point; and
       ``(II) subject to clause (ii), for each of fiscal years 
     2012 through 2019, 0.2 percentage point.

       ``(ii) Reduction of other adjustment.--Clause (i)(II) shall 
     be applied with respect to any of fiscal years 2014 through 
     2019 by substituting `0.0 percentage points' for `0.2 
     percentage point', if for such fiscal year--

       ``(I) the excess (if any) of--

       ``(aa) the total percentage of the non-elderly insured 
     population for the preceding fiscal year (based on the most 
     recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     the Patient Protection and Affordable Care Act that, if 
     determined in the affirmative, would clear such Act for 
     enrollment); over
       ``(bb) the total percentage of the non-elderly insured 
     population for such preceding fiscal year (as estimated by 
     the Secretary); exceeds

       ``(II) 5 percentage points.''.

       (e) Home Health Agencies.--Section 1895(b)(3)(B) of the 
     Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended--
       (1) in clause (ii)(V), by striking ``clause (v)'' and 
     inserting ``clauses (v) and (vi)''; and
       (2) by adding at the end the following new clause:
       ``(vi) Adjustments.--After determining the home health 
     market basket percentage increase under clause (iii), and 
     after application of clause (v), the Secretary shall reduce 
     such percentage--

       ``(I) for 2015 and each subsequent year, by the 
     productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II); and
       ``(II) for each of 2011 and 2012, by 1 percentage point.

     The application of this clause may result in the home health 
     market basket percentage increase under clause (iii) being 
     less than 0.0 for a year, and may result in payment rates 
     under the system under this subsection for a year being less 
     than such payment rates for the preceding year.''.
       (f) Psychiatric Hospitals.--Section 1886 of the Social 
     Security Act, as amended by sections 3001, 3008, 3025, and 
     3133, is amended by adding at the end the following new 
     subsection:
       ``(s) Prospective Payment for Psychiatric Hospitals.--
       ``(1) Reference to establishment and implementation of 
     system.--For provisions related to the establishment and 
     implementation of a prospective payment system for payments 
     under this title for inpatient hospital services furnished by 
     psychiatric hospitals (as described in clause (i) of 
     subsection (d)(1)(B)) and psychiatric units (as described in 
     the matter following clause (v) of such subsection), see 
     section 124 of the Medicare, Medicaid, and SCHIP Balanced 
     Budget Refinement Act of 1999.
       ``(2) Implementation for rate year beginning in 2010 and 
     subsequent rate years.--
       ``(A) In general.--In implementing the system described in 
     paragraph (1) for the rate year beginning in 2010 and any 
     subsequent rate year, any update to a base rate for days 
     during the rate year for a psychiatric hospital or unit, 
     respectively, shall be reduced--
       ``(i) for the rate year beginning in 2012 and each 
     subsequent rate year, by the productivity adjustment 
     described in section 1886(b)(3)(B)(xi)(II); and
       ``(ii) for each of the rate years beginning in 2010 through 
     2019, by the other adjustment described in paragraph (3).
       ``(B) Special rule.--The application of this paragraph may 
     result in such update being less than 0.0 for a rate year, 
     and may result in payment rates under the system described in 
     paragraph (1) for a rate year being less than such payment 
     rates for the preceding rate year.
       ``(3) Other adjustment.--
       ``(A) In general.--For purposes of paragraph (2)(A)(ii), 
     the other adjustment described in this paragraph is--
       ``(i) for each of the rate years beginning in 2010 and 
     2011, 0.25 percentage point; and
       ``(ii) subject to subparagraph (B), for each of the rate 
     years beginning in 2012 through 2019, 0.2 percentage point.
       ``(B) Reduction of other adjustment.--Subparagraph (A)(ii) 
     shall be applied with respect to any of rate years 2014 
     through 2019 by substituting `0.0 percentage points' for `0.2 
     percentage point', if for such rate year--
       ``(i) the excess (if any) of--

       ``(I) the total percentage of the non-elderly insured 
     population for the preceding rate year (based on the most 
     recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     the Patient Protection and Affordable Care Act that, if 
     determined in the affirmative, would clear such Act for 
     enrollment); over
       ``(II) the total percentage of the non-elderly insured 
     population for such preceding rate year (as estimated by the 
     Secretary); exceeds

       ``(ii) 5 percentage points.''.
       (g) Hospice Care.--Section 1814(i)(1)(C) of the Social 
     Security Act (42 U.S.C. 1395f(i)(1)(C)), as amended by 
     section 3132, is amended by adding at the end the following 
     new clauses:
       ``(iv) After determining the market basket percentage 
     increase under clause (ii)(VII) or (iii), as applicable, with 
     respect to fiscal year 2013 and each subsequent fiscal year, 
     the Secretary shall reduce such percentage--
       ``(I) for 2013 and each subsequent fiscal year, by the 
     productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II); and
       ``(II) subject to clause (v), for each of fiscal years 2013 
     through 2019, by 0.5 percentage point.

     The application of this clause may result in the market 
     basket percentage increase under clause (ii)(VII) or (iii), 
     as applicable, being less than 0.0 for a fiscal year, and may 
     result in payment rates under this subsection for a fiscal 
     year being less than such payment rates for the preceding 
     fiscal year.
       ``(v) Clause (iv)(II) shall be applied with respect to any 
     of fiscal years 2014 through 2019 by

[[Page 4301]]

     substituting `0.0 percentage points' for `0.5 percentage 
     point', if for such fiscal year--
       ``(I) the excess (if any) of--
       ``(aa) the total percentage of the non-elderly insured 
     population for the preceding fiscal year (based on the most 
     recent estimates available from the Director of the 
     Congressional Budget Office before a vote in either House on 
     the Patient Protection and Affordable Care Act that, if 
     determined in the affirmative, would clear such Act for 
     enrollment); over
       ``(bb) the total percentage of the non-elderly insured 
     population for such preceding fiscal year (as estimated by 
     the Secretary); exceeds
       ``(II) 5 percentage points.''.
       (h) Dialysis.--Section 1881(b)(14)(F) of the Social 
     Security Act (42 U.S.C. 1395rr(b)(14)(F)) is amended--
       (1) in clause (i)--
       (A) by inserting ``(I)'' after ``(F)(i)''
       (B) in subclause (I), as inserted by subparagraph (A)--
       (i) by striking ``clause (ii)'' and inserting ``subclause 
     (II) and clause (ii)''; and
       (ii) by striking ``minus 1.0 percentage point''; and
       (C) by adding at the end the following new subclause:
       ``(II) For 2012 and each subsequent year, after determining 
     the increase factor described in subclause (I), the Secretary 
     shall reduce such increase factor by the productivity 
     adjustment described in section 1886(b)(3)(B)(xi)(II). The 
     application of the preceding sentence may result in such 
     increase factor being less than 0.0 for a year, and may 
     result in payment rates under the payment system under this 
     paragraph for a year being less than such payment rates for 
     the preceding year.''; and
       (2) in clause (ii)(II)--
       (A) by striking ``The'' and inserting ``Subject to clause 
     (i)(II), the''; and
       (B) by striking ``clause (i) minus 1.0 percentage point'' 
     and inserting ``clause (i)(I)''.
       (i) Outpatient Hospitals.--Section 1833(t)(3) of the Social 
     Security Act (42 U.S.C. 1395l(t)(3)) is amended--
       (1) in subparagraph (C)(iv), by inserting ``and 
     subparagraph (F) of this paragraph'' after ``(17)''; and
       (2) by adding at the end the following new subparagraphs:
       ``(F) Productivity and other adjustment.--After determining 
     the OPD fee schedule increase factor under subparagraph 
     (C)(iv), the Secretary shall reduce such increase factor--
       ``(i) for 2012 and subsequent years, by the productivity 
     adjustment described in section 1886(b)(3)(B)(xi)(II); and
       ``(ii) for each of 2010 through 2019, by the adjustment 
     described in subparagraph (G).

     The application of this subparagraph may result in the 
     increase factor under subparagraph (C)(iv) being less than 
     0.0 for a year, and may result in payment rates under the 
     payment system under this subsection for a year being less 
     than such payment rates for the preceding year.
       ``(G) Other adjustment.--
       ``(i) Adjustment.--For purposes of subparagraph (F)(ii), 
     the adjustment described in this subparagraph is--

       ``(I) for each of 2010 and 2011, 0.25 percentage point; and
       ``(II) subject to clause (ii), for each of 2012 through 
     2019, 0.2 percentage point.

       ``(ii) Reduction of other adjustment.--Clause (i)(II) shall 
     be applied with respect to any of 2014 through 2019 by 
     substituting `0.0 percentage points' for `0.2 percentage 
     point', if for such year--

       ``(I) the excess (if any) of--

       ``(aa) the total percentage of the non-elderly insured 
     population for the preceding year (based on the most recent 
     estimates available from the Director of the Congressional 
     Budget Office before a vote in either House on the Patient 
     Protection and Affordable Care Act that, if determined in the 
     affirmative, would clear such Act for enrollment); over
       ``(bb) the total percentage of the non-elderly insured 
     population for such preceding year (as estimated by the 
     Secretary); exceeds

       ``(II) 5 percentage points.''.

       (j) Ambulance Services.--Section 1834(l)(3) of the Social 
     Security Act (42 U.S.C. 1395m(l)(3)) is amended--
       (1) in subparagraph (A), by striking ``and'' at the end;
       (2) in subparagraph (B)--
       (A) by inserting ``, subject to subparagraph (C) and the 
     succeeding sentence of this paragraph,'' after ``increased''; 
     and
       (B) by striking the period at the end and inserting ``; 
     and'';
       (3) by adding at the end the following new subparagraph:
       ``(C) for 2011 and each subsequent year, after determining 
     the percentage increase under subparagraph (B) for the year, 
     reduce such percentage increase by the productivity 
     adjustment described in section 1886(b)(3)(B)(xi)(II).''; and
       (4) by adding at the end the following flush sentence:

     ``The application of subparagraph (C) may result in the 
     percentage increase under subparagraph (B) being less than 
     0.0 for a year, and may result in payment rates under the fee 
     schedule under this subsection for a year being less than 
     such payment rates for the preceding year.''.
       (k) Ambulatory Surgical Center Services.--Section 
     1833(i)(2)(D) of the Social Security Act (42 U.S.C. 
     1395l(i)(2)(D)) is amended--
       (1) by redesignating clause (v) as clause (vi); and
       (2) by inserting after clause (iv) the following new 
     clause:
       ``(v) In implementing the system described in clause (i) 
     for 2011 and each subsequent year, any annual update under 
     such system for the year, after application of clause (iv), 
     shall be reduced by the productivity adjustment described in 
     section 1886(b)(3)(B)(xi)(II). The application of the 
     preceding sentence may result in such update being less than 
     0.0 for a year, and may result in payment rates under the 
     system described in clause (i) for a year being less than 
     such payment rates for the preceding year.''.
       (l) Laboratory Services.--Section 1833(h)(2)(A) of the 
     Social Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended--
       (1) in clause (i)--
       (A) by inserting ``, subject to clause (iv),'' after 
     ``year) by''; and
       (B) by striking ``through 2013'' and inserting ``and 
     2010''; and
       (2) by adding at the end the following new clause:
       ``(iv) After determining the adjustment to the fee 
     schedules under clause (i), the Secretary shall reduce such 
     adjustment--

       ``(I) for 2011 and each subsequent year, by the 
     productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II); and
       ``(II) for each of 2011 through 2015, by 1.75 percentage 
     points.

     Subclause (I) shall not apply in a year where the adjustment 
     to the fee schedules determined under clause (i) is 0.0 or a 
     percentage decrease for a year. The application of the 
     productivity adjustment under subclause (I) shall not result 
     in an adjustment to the fee schedules under clause (i) being 
     less than 0.0 for a year. The application of subclause (II) 
     may result in an adjustment to the fee schedules under clause 
     (i) being less than 0.0 for a year, and may result in payment 
     rates for a year being less than such payment rates for the 
     preceding year.''.
       (m) Certain Durable Medical Equipment.--Section 1834(a)(14) 
     of the Social Security Act (42 U.S.C. 1395m(a)(14)) is 
     amended--
       (1) in subparagraph (K)--
       (A) by striking ``2011, 2012, and 2013,''; and
       (B) by inserting ``and'' after the semicolon at the end;
       (2) by striking subparagraphs (L) and (M) and inserting the 
     following new subparagraph:
       ``(L) for 2011 and each subsequent year--
       ``(i) the percentage increase in the consumer price index 
     for all urban consumers (United States city average) for the 
     12-month period ending with June of the previous year, 
     reduced by--
       ``(ii) the productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II).''; and
       (3) by adding at the end the following flush sentence:

     ``The application of subparagraph (L)(ii) may result in the 
     covered item update under this paragraph being less than 0.0 
     for a year, and may result in payment rates under this 
     subsection for a year being less than such payment rates for 
     the preceding year.''.
       (n) Prosthetic Devices, Orthotics, and Prosthetics.--
     Section 1834(h)(4) of the Social Security Act (42 U.S.C. 
     1395m(h)(4)) is amended--
       (1) in subparagraph (A)--
       (A) in clause (ix), by striking ``and'' at the end;
       (B) in clause (x)--
       (i) by striking ``a subsequent year'' and inserting ``for 
     each of 2007 through 2010''; and
       (ii) by inserting ``and'' after the semicolon at the end;
       (C) by adding at the end the following new clause:
       ``(xi) for 2011 and each subsequent year--

       ``(I) the percentage increase in the consumer price index 
     for all urban consumers (United States city average) for the 
     12-month period ending with June of the previous year, 
     reduced by--
       ``(II) the productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II).''; and

       (D) by adding at the end the following flush sentence:

     ``The application of subparagraph (A)(xi)(II) may result in 
     the applicable percentage increase under subparagraph (A) 
     being less than 0.0 for a year, and may result in payment 
     rates under this subsection for a year being less than such 
     payment rates for the preceding year.''.
       (o) Other Items.--Section 1842(s)(1) of the Social Security 
     Act (42 U.S.C. 1395u(s)(1)) is amended--
       (1) in the first sentence, by striking ``Subject to'' and 
     inserting ``(A) Subject to'';
       (2) by striking the second sentence and inserting the 
     following new subparagraph:
       ``(B) Any fee schedule established under this paragraph for 
     such item or service shall be updated--
       ``(i) for years before 2011--

       ``(I) subject to subclause (II), by the percentage increase 
     in the consumer price index for all urban consumers (United 
     States city average) for the 12-month period ending with June 
     of the preceding year; and
       ``(II) for items and services described in paragraph (2)(D) 
     for 2009, section 1834(a)(14)(J) shall apply under this 
     paragraph instead of the percentage increase otherwise 
     applicable; and

       ``(ii) for 2011 and subsequent years--

       ``(I) the percentage increase in the consumer price index 
     for all urban consumers (United States city average) for the 
     12-month period ending with June of the previous year, 
     reduced by--
       ``(II) the productivity adjustment described in section 
     1886(b)(3)(B)(xi)(II).''; and

       (3) by adding at the end the following flush sentence:


[[Page 4302]]


     ``The application of subparagraph (B)(ii)(II) may result in 
     the update under this paragraph being less than 0.0 for a 
     year, and may result in payment rates under any fee schedule 
     established under this paragraph for a year being less than 
     such payment rates for the preceding year.''.
       (p) No Application Prior to April 1, 2010.--Notwithstanding 
     the preceding provisions of this section, the amendments made 
     by subsections (a), (c), and (d) shall not apply to 
     discharges occurring before April 1, 2010.

     SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART B 
                   PREMIUMS.

       Section 1839(i) of the Social Security Act (42 U.S.C. 
     1395r(i)) is amended--
       (1) in paragraph (2), in the matter preceding subparagraph 
     (A), by inserting ``subject to paragraph (6),'' after 
     ``subsection,'';
       (2) in paragraph (3)(A)(i), by striking ``The applicable'' 
     and inserting ``Subject to paragraph (6), the applicable'';
       (3) by redesignating paragraph (6) as paragraph (7); and
       (4) by inserting after paragraph (5) the following new 
     paragraph:
       ``(6) Temporary adjustment to income thresholds.--
     Notwithstanding any other provision of this subsection, 
     during the period beginning on January 1, 2011, and ending on 
     December 31, 2019--
       ``(A) the threshold amount otherwise applicable under 
     paragraph (2) shall be equal to such amount for 2010; and
       ``(B) the dollar amounts otherwise applicable under 
     paragraph (3)(C)(i) shall be equal to such dollar amounts for 
     2010.''.

     SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD.

       (a) Board.--
       (1) In general.--Title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.), as amended by section 3022, is amended 
     by adding at the end the following new section:


                 ``independent medicare advisory board

       ``Sec. 1899A.  (a) Establishment.--There is established an 
     independent board to be known as the `Independent Medicare 
     Advisory Board'.
       ``(b) Purpose.--It is the purpose of this section to, in 
     accordance with the following provisions of this section, 
     reduce the per capita rate of growth in Medicare spending--
       ``(1) by requiring the Chief Actuary of the Centers for 
     Medicare & Medicaid Services to determine in each year to 
     which this section applies (in this section referred to as `a 
     determination year') the projected per capita growth rate 
     under Medicare for the second year following the 
     determination year (in this section referred to as `an 
     implementation year');
       ``(2) if the projection for the implementation year exceeds 
     the target growth rate for that year, by requiring the Board 
     to develop and submit during the first year following the 
     determination year (in this section referred to as `a 
     proposal year') a proposal containing recommendations to 
     reduce the Medicare per capita growth rate to the extent 
     required by this section; and
       ``(3) by requiring the Secretary to implement such 
     proposals unless Congress enacts legislation pursuant to this 
     section.
       ``(c) Board Proposals.--
       ``(1) Development.--
       ``(A) In general.--The Board shall develop detailed and 
     specific proposals related to the Medicare program in 
     accordance with the succeeding provisions of this section.
       ``(B) Advisory reports.--Beginning January 15, 2014, the 
     Board may develop and submit to Congress advisory reports on 
     matters related to the Medicare program, regardless of 
     whether or not the Board submitted a proposal for such year. 
     Such a report may, for years prior to 2020, include 
     recommendations regarding improvements to payment systems for 
     providers of services and suppliers who are not otherwise 
     subject to the scope of the Board's recommendations in a 
     proposal under this section. Any advisory report submitted 
     under this subparagraph shall not be subject to the rules for 
     congressional consideration under subsection (d).
       ``(2) Proposals.--
       ``(A) Requirements.--Each proposal submitted under this 
     section in a proposal year shall meet each of the following 
     requirements:
       ``(i) If the Chief Actuary of the Centers for Medicare & 
     Medicaid Services has made a determination under paragraph 
     (7)(A) in the determination year, the proposal shall include 
     recommendations so that the proposal as a whole (after taking 
     into account recommendations under clause (v)) will result in 
     a net reduction in total Medicare program spending in the 
     implementation year that is at least equal to the applicable 
     savings target established under paragraph (7)(B) for such 
     implementation year. In determining whether a proposal meets 
     the requirement of the preceding sentence, reductions in 
     Medicare program spending during the 3-month period 
     immediately preceding the implementation year shall be 
     counted to the extent that such reductions are a result of 
     the implementation of recommendations contained in the 
     proposal for a change in the payment rate for an item or 
     service that was effective during such period pursuant to 
     subsection (e)(2)(A).
       ``(ii) The proposal shall not include any recommendation to 
     ration health care, raise revenues or Medicare beneficiary 
     premiums under section 1818, 1818A, or 1839, increase 
     Medicare beneficiary cost-sharing (including deductibles, 
     coinsurance, and copayments), or otherwise restrict benefits 
     or modify eligibility criteria.
       ``(iii) In the case of proposals submitted prior to 
     December 31, 2018, the proposal shall not include any 
     recommendation that would reduce payment rates for items and 
     services furnished, prior to December 31, 2019, by providers 
     of services (as defined in section 1861(u)) and suppliers (as 
     defined in section 1861(d)) scheduled, pursuant to the 
     amendments made by section 3401 of the Patient Protection and 
     Affordable Care Act, to receive a reduction to the 
     inflationary payment updates of such providers of services 
     and suppliers in excess of a reduction due to productivity in 
     a year in which such recommendations would take effect.
       ``(iv) As appropriate, the proposal shall include 
     recommendations to reduce Medicare payments under parts C and 
     D, such as reductions in direct subsidy payments to Medicare 
     Advantage and prescription drug plans specified under 
     paragraph (1) and (2) of section 1860D-15(a) that are related 
     to administrative expenses (including profits) for basic 
     coverage, denying high bids or removing high bids for 
     prescription drug coverage from the calculation of the 
     national average monthly bid amount under section 1860D-
     13(a)(4), and reductions in payments to Medicare Advantage 
     plans under clauses (i) and (ii) of section 1853(a)(1)(B) 
     that are related to administrative expenses (including 
     profits) and performance bonuses for Medicare Advantage plans 
     under section 1853(n). Any such recommendation shall not 
     affect the base beneficiary premium percentage specified 
     under 1860D-13(a).
       ``(v) The proposal shall include recommendations with 
     respect to administrative funding for the Secretary to carry 
     out the recommendations contained in the proposal.
       ``(vi) The proposal shall only include recommendations 
     related to the Medicare program.
       ``(B) Additional considerations.--In developing and 
     submitting each proposal under this section in a proposal 
     year, the Board shall, to the extent feasible--
       ``(i) give priority to recommendations that extend Medicare 
     solvency;
       ``(ii) include recommendations that--

       ``(I) improve the health care delivery system and health 
     outcomes, including by promoting integrated care, care 
     coordination, prevention and wellness, and quality and 
     efficiency improvement; and
       ``(II) protect and improve Medicare beneficiaries' access 
     to necessary and evidence-based items and services, including 
     in rural and frontier areas;

       ``(iii) include recommendations that target reductions in 
     Medicare program spending to sources of excess cost growth;
       ``(iv) consider the effects on Medicare beneficiaries of 
     changes in payments to providers of services (as defined in 
     section 1861(u)) and suppliers (as defined in section 
     1861(d));
       ``(v) consider the effects of the recommendations on 
     providers of services and suppliers with actual or projected 
     negative cost margins or payment updates; and
       ``(vi) consider the unique needs of Medicare beneficiaries 
     who are dually eligible for Medicare and the Medicaid program 
     under title XIX.
       ``(C) No increase in total medicare program spending.--Each 
     proposal submitted under this section shall be designed in 
     such a manner that implementation of the recommendations 
     contained in the proposal would not be expected to result, 
     over the 10-year period starting with the implementation 
     year, in any increase in the total amount of net Medicare 
     program spending relative to the total amount of net Medicare 
     program spending that would have occurred absent such 
     implementation.
       ``(D) Consultation with medpac.--The Board shall submit a 
     draft copy of each proposal to be submitted under this 
     section to the Medicare Payment Advisory Commission 
     established under section 1805 for its review. The Board 
     shall submit such draft copy by not later than September 1 of 
     the determination year.
       ``(E) Review and comment by the secretary.--The Board shall 
     submit a draft copy of each proposal to be submitted to 
     Congress under this section to the Secretary for the 
     Secretary's review and comment. The Board shall submit such 
     draft copy by not later than September 1 of the determination 
     year. Not later than March 1 of the submission year, the 
     Secretary shall submit a report to Congress on the results of 
     such review, unless the Secretary submits a proposal under 
     paragraph (5)(A) in that year.
       ``(F) Consultations.--In carrying out its duties under this 
     section, the Board shall engage in regular consultations with 
     the Medicaid and CHIP Payment and Access Commission under 
     section 1900.
       ``(3) Transmission of board proposal to president.--
       ``(A) In general.--
       ``(i) In general.--Except as provided in clause (ii) and 
     subsection (f)(3)(B), the Board shall transmit a proposal 
     under this section to the President on January 15 of each 
     year (beginning with 2014).
       ``(ii) Exception.--The Board shall not submit a proposal 
     under clause (i) in a proposal year if the year is--

       ``(I) a year for which the Chief Actuary of the Centers for 
     Medicare & Medicaid Services makes a determination in the 
     determination year under paragraph (6)(A) that the growth 
     rate described in clause (i) of such paragraph does not 
     exceed the growth rate described in clause (ii) of such 
     paragraph;
       ``(II) a year in which the Chief Actuary of the Centers for 
     Medicare & Medicaid Services makes a determination in the 
     determination year that the projected percentage increase (if 
     any) for the medical care expenditure category of the

[[Page 4303]]

     Consumer Price Index for All Urban Consumers (United States 
     city average) for the implementation year is less than the 
     projected percentage increase (if any) in the Consumer Price 
     Index for All Urban Consumers (all items; United States city 
     average) for such implementation year; or
       ``(III) for proposal year 2019 and subsequent proposal 
     years, a year in which the Chief Actuary of the Centers for 
     Medicare & Medicaid Services makes a determination in the 
     determination year that the growth rate described in 
     paragraph (8) exceeds the growth rate described in paragraph 
     (6)(A)(i).

       ``(iii) Start-up period.--The Board may not submit a 
     proposal under clause (i) prior to January 15, 2014.
       ``(B) Required information.--Each proposal submitted by the 
     Board under subparagraph (A)(i) shall include--
       ``(i) the recommendations described in paragraph (2)(A)(i);
       ``(ii) an explanation of each recommendation contained in 
     the proposal and the reasons for including such 
     recommendation;
       ``(iii) an actuarial opinion by the Chief Actuary of the 
     Centers for Medicare & Medicaid Services certifying that the 
     proposal meets the requirements of subparagraphs (A)(i) and 
     (C) of paragraph (2);
       ``(iv) a legislative proposal that implements the 
     recommendations; and
       ``(v) other information determined appropriate by the 
     Board.
       ``(4) Presidential submission to congress.--Upon receiving 
     a proposal from the Board under paragraph (3)(A)(i) or the 
     Secretary under paragraph (5), the President shall 
     immediately submit such proposal to Congress.
       ``(5) Contingent secretarial development of proposal.--If, 
     with respect to a proposal year, the Board is required, to 
     but fails, to submit a proposal to the President by the 
     deadline applicable under paragraph (3)(A)(i), the Secretary 
     shall develop a detailed and specific proposal that satisfies 
     the requirements of subparagraphs (A) and (C) (and, to the 
     extent feasible, subparagraph (B)) of paragraph (2) and 
     contains the information required paragraph (3)(B)). By not 
     later than January 25 of the year, the Secretary shall 
     transmit--
       ``(A) such proposal to the President; and
       ``(B) a copy of such proposal to the Medicare Payment 
     Advisory Commission for its review.
       ``(6) Per capita growth rate projections by chief 
     actuary.--
       ``(A) In general.--Subject to subsection (f)(3)(A), not 
     later than April 30, 2013, and annually thereafter, the Chief 
     Actuary of the Centers for Medicare & Medicaid Services shall 
     determine in each such year whether--
       ``(i) the projected Medicare per capita growth rate for the 
     implementation year (as determined under subparagraph (B)); 
     exceeds
       ``(ii) the projected Medicare per capita target growth rate 
     for the implementation year (as determined under subparagraph 
     (C)).
       ``(B) Medicare per capita growth rate.--
       ``(i) In general.--For purposes of this section, the 
     Medicare per capita growth rate for an implementation year 
     shall be calculated as the projected 5-year average (ending 
     with such year) of the growth in Medicare program spending 
     per unduplicated enrollee.
       ``(ii) Requirement.--The projection under clause (i) 
     shall--

       ``(I) to the extent that there is projected to be a 
     negative update to the single conversion factor applicable to 
     payments for physicians' services under section 1848(d) 
     furnished in the proposal year or the implementation year, 
     assume that such update for such services is 0 percent rather 
     than the negative percent that would otherwise apply; and
       ``(II) take into account any delivery system reforms or 
     other payment changes that have been enacted or published in 
     final rules but not yet implemented as of the making of such 
     calculation.

       ``(C) Medicare per capita target growth rate.--For purposes 
     of this section, the Medicare per capita target growth rate 
     for an implementation year shall be calculated as the 
     projected 5-year average (ending with such year) percentage 
     increase in--
       ``(i) with respect to a determination year that is prior to 
     2018, the average of the projected percentage increase (if 
     any) in--

       ``(I) the Consumer Price Index for All Urban Consumers (all 
     items; United States city average); and
       ``(II) the medical care expenditure category of the 
     Consumer Price Index for All Urban Consumers (United States 
     city average); and

       ``(ii) with respect to a determination year that is after 
     2017, the nominal gross domestic product per capita plus 1.0 
     percentage point.
       ``(7) Savings requirement.--
       ``(A) In general.--If, with respect to a determination 
     year, the Chief Actuary of the Centers for Medicare & 
     Medicaid Services makes a determination under paragraph 
     (6)(A) that the growth rate described in clause (i) of such 
     paragraph exceeds the growth rate described in clause (ii) of 
     such paragraph, the Chief Actuary shall establish an 
     applicable savings target for the implementation year.
       ``(B) Applicable savings target.--For purposes of this 
     section, the applicable savings target for an implementation 
     year shall be an amount equal to the product of--
       ``(i) the total amount of projected Medicare program 
     spending for the proposal year; and
       ``(ii) the applicable percent for the implementation year.
       ``(C) Applicable percent.--For purposes of subparagraph 
     (B), the applicable percent for an implementation year is the 
     lesser of--
       ``(i) in the case of--

       ``(I) implementation year 2015, 0.5 percent;
       ``(II) implementation year 2016, 1.0 percent;
       ``(III) implementation year 2017, 1.25 percent; and
       ``(IV) implementation year 2018 or any subsequent 
     implementation year, 1.5 percent; and

       ``(ii) the projected excess for the implementation year 
     (expressed as a percent) determined under subparagraph (A).
       ``(8) Per capita rate of growth in national health 
     expenditures.--In each determination year (beginning in 
     2018), the Chief Actuary of the Centers for Medicare & 
     Medicaid Services shall project the per capita rate of growth 
     in national health expenditures for the implementation year. 
     Such rate of growth for an implementation year shall be 
     calculated as the projected 5-year average (ending with such 
     year) percentage increase in national health care 
     expenditures.
       ``(d) Congressional Consideration.--
       ``(1) Introduction.--
       ``(A) In general.--On the day on which a proposal is 
     submitted by the President to the House of Representatives 
     and the Senate under subsection (c)(4), the legislative 
     proposal (described in subsection (c)(3)(B)(iv)) contained in 
     the proposal shall be introduced (by request) in the Senate 
     by the majority leader of the Senate or by Members of the 
     Senate designated by the majority leader of the Senate and 
     shall be introduced (by request) in the House by the majority 
     leader of the House or by Members of the House designated by 
     the majority leader of the House.
       ``(B) Not in session.--If either House is not in session on 
     the day on which such legislative proposal is submitted, the 
     legislative proposal shall be introduced in that House, as 
     provided in subparagraph (A), on the first day thereafter on 
     which that House is in session.
       ``(C) Any member.--If the legislative proposal is not 
     introduced in either House within 5 days on which that House 
     is in session after the day on which the legislative proposal 
     is submitted, then any Member of that House may introduce the 
     legislative proposal.
       ``(D) Referral.--The legislation introduced under this 
     paragraph shall be referred by the Presiding Officers of the 
     respective Houses to the Committee on Finance in the Senate 
     and to the Committee on Energy and Commerce and the Committee 
     on Ways and Means in the House of Representatives.
       ``(2) Committee consideration of proposal.--
       ``(A) Reporting bill.--Not later than April 1 of any 
     proposal year in which a proposal is submitted by the 
     President to Congress under this section, the Committee on 
     Ways and Means and the Committee on Energy and Commerce of 
     the House of Representatives and the Committee on Finance of 
     the Senate may report the bill referred to the Committee 
     under paragraph (1)(D) with committee amendments related to 
     the Medicare program.
       ``(B) Calculations.--In determining whether a committee 
     amendment meets the requirement of subparagraph (A), the 
     reductions in Medicare program spending during the 3-month 
     period immediately preceding the implementation year shall be 
     counted to the extent that such reductions are a result of 
     the implementation provisions in the committee amendment for 
     a change in the payment rate for an item or service that was 
     effective during such period pursuant to such amendment.
       ``(C) Committee jurisdiction.--Notwithstanding rule XV of 
     the Standing Rules of the Senate, a committee amendment 
     described in subparagraph (A) may include matter not within 
     the jurisdiction of the Committee on Finance if that matter 
     is relevant to a proposal contained in the bill submitted 
     under subsection (c)(3).
       ``(D) Discharge.--If, with respect to the House involved, 
     the committee has not reported the bill by the date required 
     by subparagraph (A), the committee shall be discharged from 
     further consideration of the proposal.
       ``(3) Limitation on changes to the board recommendations.--
       ``(A) In general.--It shall not be in order in the Senate 
     or the House of Representatives to consider any bill, 
     resolution, or amendment, pursuant to this subsection or 
     conference report thereon, that fails to satisfy the 
     requirements of subparagraphs (A)(i) and (C) of subsection 
     (c)(2).
       ``(B) Limitation on changes to the board recommendations in 
     other legislation.--It shall not be in order in the Senate or 
     the House of Representatives to consider any bill, 
     resolution, amendment, or conference report (other than 
     pursuant to this section) that would repeal or otherwise 
     change the recommendations of the Board if that change would 
     fail to satisfy the requirements of subparagraphs (A)(i) and 
     (C) of subsection (c)(2).
       ``(C) Limitation on changes to this subsection.--It shall 
     not be in order in the Senate or the House of Representatives 
     to consider any bill, resolution, amendment, or conference 
     report that would repeal or otherwise change this subsection.
       ``(D) Waiver.--This paragraph may be waived or suspended in 
     the Senate only by the affirmative vote of three-fifths of 
     the Members, duly chosen and sworn.
       ``(E) Appeals.--An affirmative vote of three-fifths of the 
     Members of the Senate, duly chosen and sworn, shall be 
     required in the Senate to sustain an appeal of the ruling of 
     the Chair on a point of order raised under this paragraph.
       ``(4) Expedited procedure.--

[[Page 4304]]

       ``(A) Consideration.--A motion to proceed to the 
     consideration of the bill in the Senate is not debatable.
       ``(B) Amendment.--
       ``(i) Time limitation.--Debate in the Senate on any 
     amendment to a bill under this section shall be limited to 1 
     hour, to be equally divided between, and controlled by, the 
     mover and the manager of the bill, and debate on any 
     amendment to an amendment, debatable motion, or appeal shall 
     be limited to 30 minutes, to be equally divided between, and 
     controlled by, the mover and the manager of the bill, except 
     that in the event the manager of the bill is in favor of any 
     such amendment, motion, or appeal, the time in opposition 
     thereto shall be controlled by the minority leader or such 
     leader's designee.
       ``(ii) Germane.--No amendment that is not germane to the 
     provisions of such bill shall be received.
       ``(iii) Additional time.--The leaders, or either of them, 
     may, from the time under their control on the passage of the 
     bill, allot additional time to any Senator during the 
     consideration of any amendment, debatable motion, or appeal.
       ``(iv) Amendment not in order.--It shall not be in order to 
     consider an amendment that would cause the bill to result in 
     a net reduction in total Medicare program spending in the 
     implementation year that is less than the applicable savings 
     target established under subsection (c)(7)(B) for such 
     implementation year.
       ``(v) Waiver and appeals.--This paragraph may be waived or 
     suspended in the Senate only by the affirmative vote of 
     three-fifths of the Members, duly chosen and sworn. An 
     affirmative vote of three-fifths of the Members of the 
     Senate, duly chosen and sworn, shall be required in the 
     Senate to sustain an appeal of the ruling of the Chair on a 
     point of order raised under this section.
       ``(C) Consideration by the other house.--
       ``(i) In general.--The expedited procedures provided in 
     this subsection for the consideration of a bill introduced 
     pursuant to paragraph (1) shall not apply to such a bill that 
     is received by one House from the other House if such a bill 
     was not introduced in the receiving House.
       ``(ii) Before passage.--If a bill that is introduced 
     pursuant to paragraph (1) is received by one House from the 
     other House, after introduction but before disposition of 
     such a bill in the receiving House, then the following shall 
     apply:

       ``(I) The receiving House shall consider the bill 
     introduced in that House through all stages of consideration 
     up to, but not including, passage.
       ``(II) The question on passage shall be put on the bill of 
     the other House as amended by the language of the receiving 
     House.

       ``(iii) After passage.--If a bill introduced pursuant to 
     paragraph (1) is received by one House from the other House, 
     after such a bill is passed by the receiving House, then the 
     vote on passage of the bill that originates in the receiving 
     House shall be considered to be the vote on passage of the 
     bill received from the other House as amended by the language 
     of the receiving House.
       ``(iv) Disposition.--Upon disposition of a bill introduced 
     pursuant to paragraph (1) that is received by one House from 
     the other House, it shall no longer be in order to consider 
     the bill that originates in the receiving House.
       ``(v) Limitation.--Clauses (ii), (iii), and (iv) shall 
     apply only to a bill received by one House from the other 
     House if the bill--

       ``(I) is related only to the program under this title; and
       ``(II) satisfies the requirements of subparagraphs (A)(i) 
     and (C) of subsection (c)(2).

       ``(D) Senate limits on debate.--
       ``(i) In general.--In the Senate, consideration of the bill 
     and on all debatable motions and appeals in connection 
     therewith shall not exceed a total of 30 hours, which shall 
     be divided equally between the majority and minority leaders 
     or their designees.
       ``(ii) Motion to further limit debate.--A motion to further 
     limit debate on the bill is in order and is not debatable.
       ``(iii) Motion or appeal.--Any debatable motion or appeal 
     is debatable for not to exceed 1 hour, to be divided equally 
     between those favoring and those opposing the motion or 
     appeal.
       ``(iv) Final disposition.--After 30 hours of consideration, 
     the Senate shall proceed, without any further debate on any 
     question, to vote on the final disposition thereof to the 
     exclusion of all amendments not then pending before the 
     Senate at that time and to the exclusion of all motions, 
     except a motion to table, or to reconsider and one quorum 
     call on demand to establish the presence of a quorum (and 
     motions required to establish a quorum) immediately before 
     the final vote begins.
       ``(E) Consideration in conference.--
       ``(i) In general.--Consideration in the Senate and the 
     House of Representatives on the conference report or any 
     messages between Houses shall be limited to 10 hours, equally 
     divided and controlled by the majority and minority leaders 
     of the Senate or their designees and the Speaker of the House 
     of Representatives and the minority leader of the House of 
     Representatives or their designees.
       ``(ii) Time limitation.--Debate in the Senate on any 
     amendment under this subparagraph shall be limited to 1 hour, 
     to be equally divided between, and controlled by, the mover 
     and the manager of the bill, and debate on any amendment to 
     an amendment, debatable motion, or appeal shall be limited to 
     30 minutes, to be equally divided between, and controlled by, 
     the mover and the manager of the bill, except that in the 
     event the manager of the bill is in favor of any such 
     amendment, motion, or appeal, the time in opposition thereto 
     shall be controlled by the minority leader or such leader's 
     designee.
       ``(iii) Final disposition.--After 10 hours of 
     consideration, the Senate shall proceed, without any further 
     debate on any question, to vote on the final disposition 
     thereof to the exclusion of all motions not then pending 
     before the Senate at that time or necessary to resolve the 
     differences between the Houses and to the exclusion of all 
     other motions, except a motion to table, or to reconsider and 
     one quorum call on demand to establish the presence of a 
     quorum (and motions required to establish a quorum) 
     immediately before the final vote begins.
       ``(iv) Limitation.--Clauses (i) through (iii) shall only 
     apply to a conference report, message or the amendments 
     thereto if the conference report, message, or an amendment 
     thereto--

       ``(I) is related only to the program under this title; and
       ``(II) satisfies the requirements of subparagraphs (A)(i) 
     and (C) of subsection (c)(2).

       ``(F) Veto.--If the President vetoes the bill debate on a 
     veto message in the Senate under this subsection shall be 1 
     hour equally divided between the majority and minority 
     leaders or their designees.
       ``(5) Rules of the senate and house of representatives.--
     This subsection and subsection (f)(2) are enacted by 
     Congress--
       ``(A) as an exercise of the rulemaking power of the Senate 
     and the House of Representatives, respectively, and is deemed 
     to be part of the rules of each House, respectively, but 
     applicable only with respect to the procedure to be followed 
     in that House in the case of bill under this section, and it 
     supersedes other rules only to the extent that it is 
     inconsistent with such rules; and
       ``(B) with full recognition of the constitutional right of 
     either House to change the rules (so far as they relate to 
     the procedure of that House) at any time, in the same manner, 
     and to the same extent as in the case of any other rule of 
     that House.
       ``(e) Implementation of Proposal.--
       ``(1) In general.--Notwithstanding any other provision of 
     law, the Secretary shall, except as provided in paragraph 
     (3), implement the recommendations contained in a proposal 
     submitted by the President to Congress pursuant to this 
     section on August 15 of the year in which the proposal is so 
     submitted.
       ``(2) Application.--
       ``(A) In general.--A recommendation described in paragraph 
     (1) shall apply as follows:
       ``(i) In the case of a recommendation that is a change in 
     the payment rate for an item or service under Medicare in 
     which payment rates change on a fiscal year basis (or a cost 
     reporting period basis that relates to a fiscal year), on a 
     calendar year basis (or a cost reporting period basis that 
     relates to a calendar year), or on a rate year basis (or a 
     cost reporting period basis that relates to a rate year), 
     such recommendation shall apply to items and services 
     furnished on the first day of the first fiscal year, calendar 
     year, or rate year (as the case may be) that begins after 
     such August 15.
       ``(ii) In the case of a recommendation relating to payments 
     to plans under parts C and D, such recommendation shall apply 
     to plan years beginning on the first day of the first 
     calendar year that begins after such August 15.
       ``(iii) In the case of any other recommendation, such 
     recommendation shall be addressed in the regular regulatory 
     process timeframe and shall apply as soon as practicable.
       ``(B) Interim final rulemaking.--The Secretary may use 
     interim final rulemaking to implement any recommendation 
     described in paragraph (1).
       ``(3) Exception.--The Secretary shall not be required to 
     implement the recommendations contained in a proposal 
     submitted in a proposal year by the President to Congress 
     pursuant to this section if--
       ``(A) prior to August 15 of the proposal year, Federal 
     legislation is enacted that includes the following provision: 
     `This Act supercedes the recommendations of the Board 
     contained in the proposal submitted, in the year which 
     includes the date of enactment of this Act, to Congress under 
     section 1899A of the Social Security Act.'; and
       ``(B) in the case of implementation year 2020 and 
     subsequent implementation years, a joint resolution described 
     in subsection (f)(1) is enacted not later than August 15, 
     2017.
       ``(4) No affect on authority to implement certain 
     provisions.--Nothing in paragraph (3) shall be construed to 
     affect the authority of the Secretary to implement any 
     recommendation contained in a proposal or advisory report 
     under this section to the extent that the Secretary otherwise 
     has the authority to implement such recommendation 
     administratively.
       ``(5) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the implementation by the Secretary 
     under this subsection of the recommendations contained in a 
     proposal.
       ``(f) Joint Resolution Required To Discontinue the Board.--
       ``(1) In general.--For purposes of subsection (e)(3)(B), a 
     joint resolution described in this paragraph means only a 
     joint resolution--
       ``(A) that is introduced in 2017 by not later than February 
     1 of such year;
       ``(B) which does not have a preamble;
       ``(C) the title of which is as follows: `Joint resolution 
     approving the discontinuation of the process for 
     consideration and automatic implementation of the annual 
     proposal of the Independent Medicare Advisory Board under 
     section 1899A of the Social Security Act'; and

[[Page 4305]]

       ``(D) the matter after the resolving clause of which is as 
     follows: `That Congress approves the discontinuation of the 
     process for consideration and automatic implementation of the 
     annual proposal of the Independent Medicare Advisory Board 
     under section 1899A of the Social Security Act.'.
       ``(2) Procedure.--
       ``(A) Referral.--A joint resolution described in paragraph 
     (1) shall be referred to the Committee on Ways and Means and 
     the Committee on Energy and Commerce of the House of 
     Representatives and the Committee on Finance of the Senate.
       ``(B) Discharge.--In the Senate, if the committee to which 
     is referred a joint resolution described in paragraph (1) has 
     not reported such joint resolution (or an identical joint 
     resolution) at the end of 20 days after the joint resolution 
     described in paragraph (1) is introduced, such committee may 
     be discharged from further consideration of such joint 
     resolution upon a petition supported in writing by 30 Members 
     of the Senate, and such joint resolution shall be placed on 
     the calendar.
       ``(C) Consideration.--
       ``(i) In general.--In the Senate, when the committee to 
     which a joint resolution is referred has reported, or when a 
     committee is discharged (under subparagraph (C)) from further 
     consideration of a joint resolution described in paragraph 
     (1), it is at any time thereafter in order (even though a 
     previous motion to the same effect has been disagreed to) for 
     a motion to proceed to the consideration of the joint 
     resolution to be made, and all points of order against the 
     joint resolution (and against consideration of the joint 
     resolution) are waived, except for points of order under the 
     Congressional Budget act of 1974 or under budget resolutions 
     pursuant to that Act. The motion is not debatable. A motion 
     to reconsider the vote by which the motion is agreed to or 
     disagreed to shall not be in order. If a motion to proceed to 
     the consideration of the joint resolution is agreed to, the 
     joint resolution shall remain the unfinished business of the 
     Senate until disposed of.
       ``(ii) Debate limitation.--In the Senate, consideration of 
     the joint resolution, and on all debatable motions and 
     appeals in connection therewith, shall be limited to not more 
     than 10 hours, which shall be divided equally between the 
     majority leader and the minority leader, or their designees. 
     A motion further to limit debate is in order and not 
     debatable. An amendment to, or a motion to postpone, or a 
     motion to proceed to the consideration of other business, or 
     a motion to recommit the joint resolution is not in order.
       ``(iii) Passage.--In the Senate, immediately following the 
     conclusion of the debate on a joint resolution described in 
     paragraph (1), and a single quorum call at the conclusion of 
     the debate if requested in accordance with the rules of the 
     Senate, the vote on passage of the joint resolution shall 
     occur.
       ``(iv) Appeals.--Appeals from the decisions of the Chair 
     relating to the application of the rules of the Senate to the 
     procedure relating to a joint resolution described in 
     paragraph (1) shall be decided without debate.
       ``(D) Other house acts first.--If, before the passage by 1 
     House of a joint resolution of that House described in 
     paragraph (1), that House receives from the other House a 
     joint resolution described in paragraph (1), then the 
     following procedures shall apply:
       ``(i) The joint resolution of the other House shall not be 
     referred to a committee.
       ``(ii) With respect to a joint resolution described in 
     paragraph (1) of the House receiving the joint resolution--

       ``(I) the procedure in that House shall be the same as if 
     no joint resolution had been received from the other House; 
     but
       ``(II) the vote on final passage shall be on the joint 
     resolution of the other House.

       ``(E) Excluded days.--For purposes of determining the 
     period specified in subparagraph (B), there shall be excluded 
     any days either House of Congress is adjourned for more than 
     3 days during a session of Congress.
       ``(F) Majority required for adoption.--A joint resolution 
     considered under this subsection shall require an affirmative 
     vote of three-fifths of the Members, duly chosen and sworn, 
     for adoption.
       ``(3) Termination.--If a joint resolution described in 
     paragraph (1) is enacted not later than August 15, 2017--
       ``(A) the Chief Actuary of the Medicare & Medicaid Services 
     shall not--
       ``(i) make any determinations under subsection (c)(6) after 
     May 1, 2017; or
       ``(ii) provide any opinion pursuant to subsection 
     (c)(3)(B)(iii) after January 16, 2018;
       ``(B) the Board shall not submit any proposals or advisory 
     reports to Congress under this section after January 16, 
     2018; and
       ``(C) the Board and the consumer advisory council under 
     subsection (k) shall terminate on August 16, 2018.
       ``(g) Board Membership; Terms of Office; Chairperson; 
     Removal.--
       ``(1) Membership.--
       ``(A) In general.--The Board shall be composed of--
       ``(i) 15 members appointed by the President, by and with 
     the advice and consent of the Senate; and
       ``(ii) the Secretary, the Administrator of the Center for 
     Medicare & Medicaid Services, and the Administrator of the 
     Health Resources and Services Administration, all of whom 
     shall serve ex officio as nonvoting members of the Board.
       ``(B) Qualifications.--
       ``(i) In general.--The appointed membership of the Board 
     shall include individuals with national recognition for their 
     expertise in health finance and economics, actuarial science, 
     health facility management, health plans and integrated 
     delivery systems, reimbursement of health facilities, 
     allopathic and osteopathic physicians, and other providers of 
     health services, and other related fields, who provide a mix 
     of different professionals, broad geographic representation, 
     and a balance between urban and rural representatives.
       ``(ii) Inclusion.--The appointed membership of the Board 
     shall include (but not be limited to) physicians and other 
     health professionals, experts in the area of pharmaco-
     economics or prescription drug benefit programs, employers, 
     third-party payers, individuals skilled in the conduct and 
     interpretation of biomedical, health services, and health 
     economics research and expertise in outcomes and 
     effectiveness research and technology assessment. Such 
     membership shall also include representatives of consumers 
     and the elderly.
       ``(iii) Majority nonproviders.--Individuals who are 
     directly involved in the provision or management of the 
     delivery of items and services covered under this title shall 
     not constitute a majority of the appointed membership of the 
     Board.
       ``(C) Ethical disclosure.--The President shall establish a 
     system for public disclosure by appointed members of the 
     Board of financial and other potential conflicts of interest 
     relating to such members. Appointed members of the Board 
     shall be treated as officers in the executive branch for 
     purposes of applying title I of the Ethics in Government Act 
     of 1978 (Public Law 95-521).
       ``(D) Conflicts of interest.--No individual may serve as an 
     appointed member if that individual engages in any other 
     business, vocation, or employment.
       ``(E) Consultation with congress.--In selecting individuals 
     for nominations for appointments to the Board, the President 
     shall consult with--
       ``(i) the majority leader of the Senate concerning the 
     appointment of 3 members;
       ``(ii) the Speaker of the House of Representatives 
     concerning the appointment of 3 members;
       ``(iii) the minority leader of the Senate concerning the 
     appointment of 3 members; and
       ``(iv) the minority leader of the House of Representatives 
     concerning the appointment of 3 members.
       ``(2) Term of office.--Each appointed member shall hold 
     office for a term of 6 years except that--
       ``(A) a member may not serve more than 2 full consecutive 
     terms (but may be reappointed to 2 full consecutive terms 
     after being appointed to fill a vacancy on the Board);
       ``(B) a member appointed to fill a vacancy occurring prior 
     to the expiration of the term for which that member's 
     predecessor was appointed shall be appointed for the 
     remainder of such term;
       ``(C) a member may continue to serve after the expiration 
     of the member's term until a successor has taken office; and
       ``(D) of the members first appointed under this section, 5 
     shall be appointed for a term of 1 year, 5 shall be appointed 
     for a term of 3 years, and 5 shall be appointed for a term of 
     6 years, the term of each to be designated by the President 
     at the time of nomination.
       ``(3) Chairperson.--
       ``(A) In general.--The Chairperson shall be appointed by 
     the President, by and with the advice and consent of the 
     Senate, from among the members of the Board.
       ``(B) Duties.--The Chairperson shall be the principal 
     executive officer of the Board, and shall exercise all of the 
     executive and administrative functions of the Board, 
     including functions of the Board with respect to--
       ``(i) the appointment and supervision of personnel employed 
     by the Board;
       ``(ii) the distribution of business among personnel 
     appointed and supervised by the Chairperson and among 
     administrative units of the Board; and
       ``(iii) the use and expenditure of funds.
       ``(C) Governance.--In carrying out any of the functions 
     under subparagraph (B), the Chairperson shall be governed by 
     the general policies established by the Board and by the 
     decisions, findings, and determinations the Board shall by 
     law be authorized to make.
       ``(D) Requests for appropriations.--Requests or estimates 
     for regular, supplemental, or deficiency appropriations on 
     behalf of the Board may not be submitted by the Chairperson 
     without the prior approval of a majority vote of the Board.
       ``(4) Removal.--Any appointed member may be removed by the 
     President for neglect of duty or malfeasance in office, but 
     for no other cause.
       ``(h) Vacancies; Quorum; Seal; Vice Chairperson; Voting on 
     Reports.--
       ``(1) Vacancies.--No vacancy on the Board shall impair the 
     right of the remaining members to exercise all the powers of 
     the Board.
       ``(2) Quorum.--A majority of the appointed members of the 
     Board shall constitute a quorum for the transaction of 
     business, but a lesser number of members may hold hearings.
       ``(3) Seal.--The Board shall have an official seal, of 
     which judicial notice shall be taken.
       ``(4) Vice chairperson.--The Board shall annually elect a 
     Vice Chairperson to act in the absence or disability of the 
     Chairperson or in case of a vacancy in the office of the 
     Chairperson.
       ``(5) Voting on proposals.--Any proposal of the Board must 
     be approved by the majority of appointed members present.

[[Page 4306]]

       ``(i) Powers of the Board.--
       ``(1) Hearings.--The Board may hold such hearings, sit and 
     act at such times and places, take such testimony, and 
     receive such evidence as the Board considers advisable to 
     carry out this section.
       ``(2) Authority to inform research priorities for data 
     collection.--The Board may advise the Secretary on priorities 
     for health services research, particularly as such priorities 
     pertain to necessary changes and issues regarding payment 
     reforms under Medicare.
       ``(3) Obtaining official data.--The Board may secure 
     directly from any department or agency of the United States 
     information necessary to enable it to carry out this section. 
     Upon request of the Chairperson, the head of that department 
     or agency shall furnish that information to the Board on an 
     agreed upon schedule.
       ``(4) Postal services.--The Board may use the United States 
     mails in the same manner and under the same conditions as 
     other departments and agencies of the Federal Government.
       ``(5) Gifts.--The Board may accept, use, and dispose of 
     gifts or donations of services or property.
       ``(6) Offices.--The Board shall maintain a principal office 
     and such field offices as it determines necessary, and may 
     meet and exercise any of its powers at any other place.
       ``(j) Personnel Matters.--
       ``(1) Compensation of members and chairperson.--Each 
     appointed member, other than the Chairperson, shall be 
     compensated at a rate equal to the annual rate of basic pay 
     prescribed for level III of the Executive Schedule under 
     section 5315 of title 5, United States Code. The Chairperson 
     shall be compensated at a rate equal to the daily equivalent 
     of the annual rate of basic pay prescribed for level II of 
     the Executive Schedule under section 5315 of title 5, United 
     States Code.
       ``(2) Travel expenses.--The appointed members shall be 
     allowed travel expenses, including per diem in lieu of 
     subsistence, at rates authorized for employees of agencies 
     under subchapter I of chapter 57 of title 5, United States 
     Code, while away from their homes or regular places of 
     business in the performance of services for the Board.
       ``(3) Staff.--
       ``(A) In general.--The Chairperson may, without regard to 
     the civil service laws and regulations, appoint and terminate 
     an executive director and such other additional personnel as 
     may be necessary to enable the Board to perform its duties. 
     The employment of an executive director shall be subject to 
     confirmation by the Board.
       ``(B) Compensation.--The Chairperson may fix the 
     compensation of the executive director and other personnel 
     without regard to chapter 51 and subchapter III of chapter 53 
     of title 5, United States Code, relating to classification of 
     positions and General Schedule pay rates, except that the 
     rate of pay for the executive director and other personnel 
     may not exceed the rate payable for level V of the Executive 
     Schedule under section 5316 of such title.
       ``(4) Detail of government employees.--Any Federal 
     Government employee may be detailed to the Board without 
     reimbursement, and such detail shall be without interruption 
     or loss of civil service status or privilege.
       ``(5) Procurement of temporary and intermittent services.--
     The Chairperson may procure temporary and intermittent 
     services under section 3109(b) of title 5, United States 
     Code, at rates for individuals which do not exceed the daily 
     equivalent of the annual rate of basic pay prescribed for 
     level V of the Executive Schedule under section 5316 of such 
     title.
       ``(k) Consumer Advisory Council.--
       ``(1) In general.--There is established a consumer advisory 
     council to advise the Board on the impact of payment policies 
     under this title on consumers.
       ``(2) Membership.--
       ``(A) Number and appointment.--The consumer advisory 
     council shall be composed of 10 consumer representatives 
     appointed by the Comptroller General of the United States, 1 
     from among each of the 10 regions established by the 
     Secretary as of the date of enactment of this section.
       ``(B) Qualifications.--The membership of the council shall 
     represent the interests of consumers and particular 
     communities.
       ``(3) Duties.--The consumer advisory council shall, subject 
     to the call of the Board, meet not less frequently than 2 
     times each year in the District of Columbia.
       ``(4) Open meetings.--Meetings of the consumer advisory 
     council shall be open to the public.
       ``(5) Election of officers.--Members of the consumer 
     advisory council shall elect their own officers.
       ``(6) Application of faca.--The Federal Advisory Committee 
     Act (5 U.S.C. App.) shall apply to the consumer advisory 
     council except that section 14 of such Act shall not apply.
       ``(l) Definitions.--In this section:
       ``(1) Board; chairperson; member.--The terms `Board', 
     `Chairperson', and `Member' mean the Independent Medicare 
     Advisory Board established under subsection (a) and the 
     Chairperson and any Member thereof, respectively.
       ``(2) Medicare.--The term `Medicare' means the program 
     established under this title, including parts A, B, C, and D.
       ``(3) Medicare beneficiary.--The term `Medicare 
     beneficiary' means an individual who is entitled to, or 
     enrolled for, benefits under part A or enrolled for benefits 
     under part B.
       ``(4) Medicare program spending.--The term `Medicare 
     program spending' means program spending under parts A, B, 
     and D net of premiums.
       ``(m) Funding.--
       ``(1) In general.--There are appropriated to the Board to 
     carry out its duties and functions--
       ``(A) for fiscal year 2012, $15,000,000; and
       ``(B) for each subsequent fiscal year, the amount 
     appropriated under this paragraph for the previous fiscal 
     year increased by the annual percentage increase in the 
     Consumer Price Index for All Urban Consumers (all items; 
     United States city average) as of June of the previous fiscal 
     year.
       ``(2) From trust funds.--Sixty percent of amounts 
     appropriated under paragraph (1) shall be derived by transfer 
     from the Federal Hospital Insurance Trust Fund under section 
     1817 and 40 percent of amounts appropriated under such 
     paragraph shall be derived by transfer from the Federal 
     Supplementary Medical Insurance Trust Fund under section 
     1841.''.
       (2) Lobbying cooling-off period for members of the 
     independent medicare advisory board.--Section 207(c) of title 
     18, United States Code, is amended by inserting at the end 
     the following:
       ``(3) Members of the independent medicare advisory board.--
       ``(A) In general.--Paragraph (1) shall apply to a member of 
     the Independent Medicare Advisory Board under section 1899A.
       ``(B) Agencies and congress.--For purposes of paragraph 
     (1), the agency in which the individual described in 
     subparagraph (A) served shall be considered to be the 
     Independent Medicare Advisory Board, the Department of Health 
     and Human Services, and the relevant committees of 
     jurisdiction of Congress, including the Committee on Ways and 
     Means and the Committee on Energy and Commerce of the House 
     of Representatives and the Committee on Finance of the 
     Senate.''.
       (b) GAO Study and Report on Determination and 
     Implementation of Payment and Coverage Policies Under the 
     Medicare Program.--
       (1) Initial study and report.--
       (A) Study.--The Comptroller General of the United States 
     (in this section referred to as the ``Comptroller General'') 
     shall conduct a study on changes to payment policies, 
     methodologies, and rates and coverage policies and 
     methodologies under the Medicare program under title XVIII of 
     the Social Security Act as a result of the recommendations 
     contained in the proposals made by the Independent Medicare 
     Advisory Board under section 1899A of such Act (as added by 
     subsection (a)), including an analysis of the effect of such 
     recommendations on--
       (i) Medicare beneficiary access to providers and items and 
     services;
       (ii) the affordability of Medicare premiums and cost-
     sharing (including deductibles, coinsurance, and copayments);
       (iii) the potential impact of changes on other government 
     or private-sector purchasers and payers of care; and
       (iv) quality of patient care, including patient experience, 
     outcomes, and other measures of care.
       (B) Report.--Not later than July 1, 2015, the Comptroller 
     General shall submit to Congress a report containing the 
     results of the study conducted under subparagraph (A), 
     together with recommendations for such legislation and 
     administrative action as the Comptroller General determines 
     appropriate.
       (2) Subsequent studies and reports.--The Comptroller 
     General shall periodically conduct such additional studies 
     and submit reports to Congress on changes to Medicare 
     payments policies, methodologies, and rates and coverage 
     policies and methodologies as the Comptroller General 
     determines appropriate, in consultation with the Committee on 
     Ways and Means and the Committee on Energy and Commerce of 
     the House of Representatives and the Committee on Finance of 
     the Senate.
       (c) Conforming Amendments.--Section 1805(b) of the Social 
     Security Act (42 U.S.C. 1395b-6(b)) is amended--
       (1) by redesignating paragraphs (4) through (8) as 
     paragraphs (5) through (9), respectively; and
       (2) by inserting after paragraph (3) the following:
       ``(4) Review and comment on the independent medicare 
     advisory board or secretarial proposal.--If the Independent 
     Medicare Advisory Board (as established under subsection (a) 
     of section 1899A) or the Secretary submits a proposal to the 
     Commission under such section in a year, the Commission shall 
     review the proposal and, not later than March 1 of that year, 
     submit to the Committee on Ways and Means and the Committee 
     on Energy and Commerce of the House of Representatives and 
     the Committee on Finance of the Senate written comments on 
     such proposal. Such comments may include such recommendations 
     as the Commission deems appropriate.''.

              Subtitle F--Health Care Quality Improvements

     SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY 
                   IMPROVEMENT TECHNICAL ASSISTANCE.

       Part D of title IX of the Public Health Service Act, as 
     amended by section 3013, is further amended by adding at the 
     end the following:

[[Page 4307]]



         ``Subpart II--Health Care Quality Improvement Programs

     ``SEC. 933. HEALTH CARE DELIVERY SYSTEM RESEARCH.

       ``(a) Purpose.--The purposes of this section are to--
       ``(1) enable the Director to identify, develop, evaluate, 
     disseminate, and provide training in innovative methodologies 
     and strategies for quality improvement practices in the 
     delivery of health care services that represent best 
     practices (referred to as `best practices') in health care 
     quality, safety, and value; and
       ``(2) ensure that the Director is accountable for 
     implementing a model to pursue such research in a 
     collaborative manner with other related Federal agencies.
       ``(b) General Functions of the Center.--The Center for 
     Quality Improvement and Patient Safety of the Agency for 
     Healthcare Research and Quality (referred to in this section 
     as the `Center'), or any other relevant agency or department 
     designated by the Director, shall--
       ``(1) carry out its functions using research from a variety 
     of disciplines, which may include epidemiology, health 
     services, sociology, psychology, human factors engineering, 
     biostatistics, health economics, clinical research, and 
     health informatics;
       ``(2) conduct or support activities consistent with the 
     purposes described in subsection (a), and for--
       ``(A) best practices for quality improvement practices in 
     the delivery of health care services; and
       ``(B) that include changes in processes of care and the 
     redesign of systems used by providers that will reliably 
     result in intended health outcomes, improve patient safety, 
     and reduce medical errors (such as skill development for 
     health care providers in team-based health care delivery and 
     rapid cycle process improvement) and facilitate adoption of 
     improved workflow;
       ``(3) identify health care providers, including health care 
     systems, single institutions, and individual providers, 
     that--
       ``(A) deliver consistently high-quality, efficient health 
     care services (as determined by the Secretary); and
       ``(B) employ best practices that are adaptable and scalable 
     to diverse health care settings or effective in improving 
     care across diverse settings;
       ``(4) assess research, evidence, and knowledge about what 
     strategies and methodologies are most effective in improving 
     health care delivery;
       ``(5) find ways to translate such information rapidly and 
     effectively into practice, and document the sustainability of 
     those improvements;
       ``(6) create strategies for quality improvement through the 
     development of tools, methodologies, and interventions that 
     can successfully reduce variations in the delivery of health 
     care;
       ``(7) identify, measure, and improve organizational, human, 
     or other causative factors, including those related to the 
     culture and system design of a health care organization, that 
     contribute to the success and sustainability of specific 
     quality improvement and patient safety strategies;
       ``(8) provide for the development of best practices in the 
     delivery of health care services that--
       ``(A) have a high likelihood of success, based on 
     structured review of empirical evidence;
       ``(B) are specified with sufficient detail of the 
     individual processes, steps, training, skills, and knowledge 
     required for implementation and incorporation into workflow 
     of health care practitioners in a variety of settings;
       ``(C) are designed to be readily adapted by health care 
     providers in a variety of settings; and
       ``(D) where applicable, assist health care providers in 
     working with other health care providers across the continuum 
     of care and in engaging patients and their families in 
     improving the care and patient health outcomes;
       ``(9) provide for the funding of the activities of 
     organizations with recognized expertise and excellence in 
     improving the delivery of health care services, including 
     children's health care, by involving multiple disciplines, 
     managers of health care entities, broad development and 
     training, patients, caregivers and families, and frontline 
     health care workers, including activities for the examination 
     of strategies to share best quality improvement practices and 
     to promote excellence in the delivery of health care 
     services; and
       ``(10) build capacity at the State and community level to 
     lead quality and safety efforts through education, training, 
     and mentoring programs to carry out the activities under 
     paragraphs (1) through (9).
       ``(c) Research Functions of Center.--
       ``(1) In general.--The Center shall support, such as 
     through a contract or other mechanism, research on health 
     care delivery system improvement and the development of tools 
     to facilitate adoption of best practices that improve the 
     quality, safety, and efficiency of health care delivery 
     services. Such support may include establishing a Quality 
     Improvement Network Research Program for the purpose of 
     testing, scaling, and disseminating of interventions to 
     improve quality and efficiency in health care. Recipients of 
     funding under the Program may include national, State, multi-
     State, or multi-site quality improvement networks.
       ``(2) Research requirements.--The research conducted 
     pursuant to paragraph (1) shall--
       ``(A) address the priorities identified by the Secretary in 
     the national strategic plan established under section 399HH;
       ``(B) identify areas in which evidence is insufficient to 
     identify strategies and methodologies, taking into 
     consideration areas of insufficient evidence identified by 
     the entity with a contract under section 1890(a) of the 
     Social Security Act in the report required under section 
     399JJ;
       ``(C) address concerns identified by health care 
     institutions and providers and communicated through the 
     Center pursuant to subsection (d);
       ``(D) reduce preventable morbidity, mortality, and 
     associated costs of morbidity and mortality by building 
     capacity for patient safety research;
       ``(E) support the discovery of processes for the reliable, 
     safe, efficient, and responsive delivery of health care, 
     taking into account discoveries from clinical research and 
     comparative effectiveness research;
       ``(F) allow communication of research findings and 
     translate evidence into practice recommendations that are 
     adaptable to a variety of settings, and which, as soon as 
     practicable after the establishment of the Center, shall 
     include--
       ``(i) the implementation of a national application of 
     Intensive Care Unit improvement projects relating to the 
     adult (including geriatric), pediatric, and neonatal patient 
     populations;
       ``(ii) practical methods for addressing health care 
     associated infections, including Methicillin-Resistant 
     Staphylococcus Aureus and Vancomycin-Resistant Entercoccus 
     infections and other emerging infections; and
       ``(iii) practical methods for reducing preventable hospital 
     admissions and readmissions;
       ``(G) expand demonstration projects for improving the 
     quality of children's health care and the use of health 
     information technology, such as through Pediatric Quality 
     Improvement Collaboratives and Learning Networks, consistent 
     with provisions of section 1139A of the Social Security Act 
     for assessing and improving quality, where applicable;
       ``(H) identify and mitigate hazards by--
       ``(i) analyzing events reported to patient safety reporting 
     systems and patient safety organizations; and
       ``(ii) using the results of such analyses to develop 
     scientific methods of response to such events;
       ``(I) include the conduct of systematic reviews of existing 
     practices that improve the quality, safety, and efficiency of 
     health care delivery, as well as new research on improving 
     such practices; and
       ``(J) include the examination of how to measure and 
     evaluate the progress of quality and patient safety 
     activities.
       ``(d) Dissemination of Research Findings.--
       ``(1) Public availability.--The Director shall make the 
     research findings of the Center available to the public 
     through multiple media and appropriate formats to reflect the 
     varying needs of health care providers and consumers and 
     diverse levels of health literacy.
       ``(2) Linkage to health information technology.--The 
     Secretary shall ensure that research findings and results 
     generated by the Center are shared with the Office of the 
     National Coordinator of Health Information Technology and 
     used to inform the activities of the health information 
     technology extension program under section 3012, as well as 
     any relevant standards, certification criteria, or 
     implementation specifications.
       ``(e) Prioritization.--The Director shall identify and 
     regularly update a list of processes or systems on which to 
     focus research and dissemination activities of the Center, 
     taking into account--
       ``(1) the cost to Federal health programs;
       ``(2) consumer assessment of health care experience;
       ``(3) provider assessment of such processes or systems and 
     opportunities to minimize distress and injury to the health 
     care workforce;
       ``(4) the potential impact of such processes or systems on 
     health status and function of patients, including vulnerable 
     populations including children;
       ``(5) the areas of insufficient evidence identified under 
     subsection (c)(2)(B); and
       ``(6) the evolution of meaningful use of health information 
     technology, as defined in section 3000.
       ``(f) Coordination.--The Center shall coordinate its 
     activities with activities conducted by the Center for 
     Medicare and Medicaid Innovation established under section 
     1115A of the Social Security Act.
       ``(g) Funding.--There is authorized to be appropriated to 
     carry out this section $20,000,000 for fiscal years 2010 
     through 2014.

     ``SEC. 934. QUALITY IMPROVEMENT TECHNICAL ASSISTANCE AND 
                   IMPLEMENTATION.

       ``(a) In General.--The Director, through the Center for 
     Quality Improvement and Patient Safety of the Agency for 
     Healthcare Research and Quality (referred to in this section 
     as the `Center'), shall award--
       ``(1) technical assistance grants or contracts to eligible 
     entities to provide technical support to institutions that 
     deliver health care and health care providers (including 
     rural and urban providers of services and suppliers with 
     limited infrastructure and financial resources to implement 
     and support quality improvement activities, providers of 
     services and suppliers with poor performance scores, and 
     providers of services and suppliers for which there are 
     disparities in care among subgroups of patients) so that such 
     institutions and providers understand, adapt, and implement 
     the models and practices identified in the research conducted 
     by the Center, including the Quality Improvement Networks 
     Research Program; and
       ``(2) implementation grants or contracts to eligible 
     entities to implement the models and practices described 
     under paragraph (1).
       ``(b) Eligible Entities.--
       ``(1) Technical assistance award.--To be eligible to 
     receive a technical assistance grant or contract under 
     subsection (a)(1), an entity--

[[Page 4308]]

       ``(A) may be a health care provider, health care provider 
     association, professional society, health care worker 
     organization, Indian health organization, quality improvement 
     organization, patient safety organization, local quality 
     improvement collaborative, the Joint Commission, academic 
     health center, university, physician-based research network, 
     primary care extension program established under section 
     399W, a Federal Indian Health Service program or a health 
     program operated by an Indian tribe (as defined in section 4 
     of the Indian Health Care Improvement Act), or any other 
     entity identified by the Secretary; and
       ``(B) shall have demonstrated expertise in providing 
     information and technical support and assistance to health 
     care providers regarding quality improvement.
       ``(2) Implementation award.--To be eligible to receive an 
     implementation grant or contract under subsection (a)(2), an 
     entity--
       ``(A) may be a hospital or other health care provider or 
     consortium or providers, as determined by the Secretary; and
       ``(B) shall have demonstrated expertise in providing 
     information and technical support and assistance to health 
     care providers regarding quality improvement.
       ``(c) Application.--
       ``(1) Technical assistance award.--To receive a technical 
     assistance grant or contract under subsection (a)(1), an 
     eligible entity shall submit an application to the Secretary 
     at such time, in such manner, and containing--
       ``(A) a plan for a sustainable business model that may 
     include a system of--
       ``(i) charging fees to institutions and providers that 
     receive technical support from the entity; and
       ``(ii) reducing or eliminating such fees for such 
     institutions and providers that serve low-income populations; 
     and
       ``(B) such other information as the Director may require.
       ``(2) Implementation award.--To receive a grant or contract 
     under subsection (a)(2), an eligible entity shall submit an 
     application to the Secretary at such time, in such manner, 
     and containing--
       ``(A) a plan for implementation of a model or practice 
     identified in the research conducted by the Center 
     including--
       ``(i) financial cost, staffing requirements, and timeline 
     for implementation; and
       ``(ii) pre- and projected post-implementation quality 
     measure performance data in targeted improvement areas 
     identified by the Secretary; and
       ``(B) such other information as the Director may require.
       ``(d) Matching Funds.--The Director may not award a grant 
     or contract under this section to an entity unless the entity 
     agrees that it will make available (directly or through 
     contributions from other public or private entities) non-
     Federal contributions toward the activities to be carried out 
     under the grant or contract in an amount equal to $1 for each 
     $5 of Federal funds provided under the grant or contract. 
     Such non-Federal matching funds may be provided directly or 
     through donations from public or private entities and may be 
     in cash or in-kind, fairly evaluated, including plant, 
     equipment, or services.
       ``(e) Evaluation.--
       ``(1) In general.--The Director shall evaluate the 
     performance of each entity that receives a grant or contract 
     under this section. The evaluation of an entity shall include 
     a study of--
       ``(A) the success of such entity in achieving the 
     implementation, by the health care institutions and providers 
     assisted by such entity, of the models and practices 
     identified in the research conducted by the Center under 
     section 933;
       ``(B) the perception of the health care institutions and 
     providers assisted by such entity regarding the value of the 
     entity; and
       ``(C) where practicable, better patient health outcomes and 
     lower cost resulting from the assistance provided by such 
     entity.
       ``(2) Effect of evaluation.--Based on the outcome of the 
     evaluation of the entity under paragraph (1), the Director 
     shall determine whether to renew a grant or contract with 
     such entity under this section.
       ``(f) Coordination.--The entities that receive a grant or 
     contract under this section shall coordinate with health 
     information technology regional extension centers under 
     section 3012(c) and the primary care extension program 
     established under section 399W regarding the dissemination of 
     quality improvement, system delivery reform, and best 
     practices information.''.

     SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE 
                   PATIENT-CENTERED MEDICAL HOME.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     establish a program to provide grants to or enter into 
     contracts with eligible entities to establish community-based 
     interdisciplinary, interprofessional teams (referred to in 
     this section as ``health teams'') to support primary care 
     practices, including obstetrics and gynecology practices, 
     within the hospital service areas served by the eligible 
     entities. Grants or contracts shall be used to--
       (1) establish health teams to provide support services to 
     primary care providers; and
       (2) provide capitated payments to primary care providers as 
     determined by the Secretary.
       (b) Eligible Entities.--To be eligible to receive a grant 
     or contract under subsection (a), an entity shall--
       (1)(A) be a State or State-designated entity; or
       (B) be an Indian tribe or tribal organization, as defined 
     in section 4 of the Indian Health Care Improvement Act;
       (2) submit a plan for achieving long-term financial 
     sustainability within 3 years;
       (3) submit a plan for incorporating prevention initiatives 
     and patient education and care management resources into the 
     delivery of health care that is integrated with community-
     based prevention and treatment resources, where available;
       (4) ensure that the health team established by the entity 
     includes an interdisciplinary, interprofessional team of 
     health care providers, as determined by the Secretary; such 
     team may include medical specialists, nurses, pharmacists, 
     nutritionists, dieticians, social workers, behavioral and 
     mental health providers (including substance use disorder 
     prevention and treatment providers), doctors of chiropractic, 
     licensed complementary and alternative medicine 
     practitioners, and physicians' assistants;
       (5) agree to provide services to eligible individuals with 
     chronic conditions, as described in section 1945 of the 
     Social Security Act (as added by section 2703), in accordance 
     with the payment methodology established under subsection (c) 
     of such section; and
       (6) submit to the Secretary an application at such time, in 
     such manner, and containing such information as the Secretary 
     may require.
       (c) Requirements for Health Teams.--A health team 
     established pursuant to a grant or contract under subsection 
     (a) shall--
       (1) establish contractual agreements with primary care 
     providers to provide support services;
       (2) support patient-centered medical homes, defined as a 
     mode of care that includes--
       (A) personal physicians;
       (B) whole person orientation;
       (C) coordinated and integrated care;
       (D) safe and high-quality care through evidence-informed 
     medicine, appropriate use of health information technology, 
     and continuous quality improvements;
       (E) expanded access to care; and
       (F) payment that recognizes added value from additional 
     components of patient-centered care;
       (3) collaborate with local primary care providers and 
     existing State and community based resources to coordinate 
     disease prevention, chronic disease management, transitioning 
     between health care providers and settings and case 
     management for patients, including children, with priority 
     given to those amenable to prevention and with chronic 
     diseases or conditions identified by the Secretary;
       (4) in collaboration with local health care providers, 
     develop and implement interdisciplinary, interprofessional 
     care plans that integrate clinical and community preventive 
     and health promotion services for patients, including 
     children, with a priority given to those amenable to 
     prevention and with chronic diseases or conditions identified 
     by the Secretary;
       (5) incorporate health care providers, patients, 
     caregivers, and authorized representatives in program design 
     and oversight;
       (6) provide support necessary for local primary care 
     providers to--
       (A) coordinate and provide access to high-quality health 
     care services;
       (B) coordinate and provide access to preventive and health 
     promotion services;
       (C) provide access to appropriate specialty care and 
     inpatient services;
       (D) provide quality-driven, cost-effective, culturally 
     appropriate, and patient- and family-centered health care;
       (E) provide access to pharmacist-delivered medication 
     management services, including medication reconciliation;
       (F) provide coordination of the appropriate use of 
     complementary and alternative (CAM) services to those who 
     request such services;
       (G) promote effective strategies for treatment planning, 
     monitoring health outcomes and resource use, sharing 
     information, treatment decision support, and organizing care 
     to avoid duplication of service and other medical management 
     approaches intended to improve quality and value of health 
     care services;
       (H) provide local access to the continuum of health care 
     services in the most appropriate setting, including access to 
     individuals that implement the care plans of patients and 
     coordinate care, such as integrative health care 
     practitioners;
       (I) collect and report data that permits evaluation of the 
     success of the collaborative effort on patient outcomes, 
     including collection of data on patient experience of care, 
     and identification of areas for improvement; and
       (J) establish a coordinated system of early identification 
     and referral for children at risk for developmental or 
     behavioral problems such as through the use of infolines, 
     health information technology, or other means as determined 
     by the Secretary;
       (7) provide 24-hour care management and support during 
     transitions in care settings including--
       (A) a transitional care program that provides onsite visits 
     from the care coordinator, assists with the development of 
     discharge plans and medication reconciliation upon admission 
     to and discharge from the hospitals, nursing home, or other 
     institution setting;
       (B) discharge planning and counseling support to providers, 
     patients, caregivers, and authorized representatives;
       (C) assuring that post-discharge care plans include 
     medication management, as appropriate;
       (D) referrals for mental and behavioral health services, 
     which may include the use of infolines; and
       (E) transitional health care needs from adolescence to 
     adulthood;

[[Page 4309]]

       (8) serve as a liaison to community prevention and 
     treatment programs;
       (9) demonstrate a capacity to implement and maintain health 
     information technology that meets the requirements of 
     certified EHR technology (as defined in section 3000 of the 
     Public Health Service Act (42 U.S.C. 300jj)) to facilitate 
     coordination among members of the applicable care team and 
     affiliated primary care practices; and
       (10) where applicable, report to the Secretary information 
     on quality measures used under section 399JJ of the Public 
     Health Service Act.
       (d) Requirement for Primary Care Providers.--A provider who 
     contracts with a care team shall--
       (1) provide a care plan to the care team for each patient 
     participant;
       (2) provide access to participant health records; and
       (3) meet regularly with the care team to ensure integration 
     of care.
       (e) Reporting to Secretary.--An entity that receives a 
     grant or contract under subsection (a) shall submit to the 
     Secretary a report that describes and evaluates, as requested 
     by the Secretary, the activities carried out by the entity 
     under subsection (c).
       (f) Definition of Primary Care.--In this section, the term 
     ``primary care'' means the provision of integrated, 
     accessible health care services by clinicians who are 
     accountable for addressing a large majority of personal 
     health care needs, developing a sustained partnership with 
     patients, and practicing in the context of family and 
     community.

     SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF 
                   CHRONIC DISEASE.

       Title IX of the Public Health Service Act (42 U.S.C. 299 et 
     seq.), as amended by section 3501, is further amended by 
     inserting after section 934 the following:

     ``SEC. 935. GRANTS OR CONTRACTS TO IMPLEMENT MEDICATION 
                   MANAGEMENT SERVICES IN TREATMENT OF CHRONIC 
                   DISEASES.

       ``(a) In General.--The Secretary, acting through the 
     Patient Safety Research Center established in section 933 
     (referred to in this section as the `Center'), shall 
     establish a program to provide grants or contracts to 
     eligible entities to implement medication management 
     (referred to in this section as `MTM') services provided by 
     licensed pharmacists, as a collaborative, multidisciplinary, 
     inter-professional approach to the treatment of chronic 
     diseases for targeted individuals, to improve the quality of 
     care and reduce overall cost in the treatment of such 
     diseases. The Secretary shall commence the program under this 
     section not later than May 1, 2010.
       ``(b) Eligible Entities.--To be eligible to receive a grant 
     or contract under subsection (a), an entity shall--
       ``(1) provide a setting appropriate for MTM services, as 
     recommended by the experts described in subsection (e);
       ``(2) submit to the Secretary a plan for achieving long-
     term financial sustainability;
       ``(3) where applicable, submit a plan for coordinating MTM 
     services through local community health teams established in 
     section 3502 of the Patient Protection and Affordable Care 
     Act or in collaboration with primary care extension programs 
     established in section 399W;
       ``(4) submit a plan for meeting the requirements under 
     subsection (c); and
       ``(5) submit to the Secretary such other information as the 
     Secretary may require.
       ``(c) MTM Services to Targeted Individuals.--The MTM 
     services provided with the assistance of a grant or contract 
     awarded under subsection (a) shall, as allowed by State law 
     including applicable collaborative pharmacy practice 
     agreements, include--
       ``(1) performing or obtaining necessary assessments of the 
     health and functional status of each patient receiving such 
     MTM services;
       ``(2) formulating a medication treatment plan according to 
     therapeutic goals agreed upon by the prescriber and the 
     patient or caregiver or authorized representative of the 
     patient;
       ``(3) selecting, initiating, modifying, recommending 
     changes to, or administering medication therapy;
       ``(4) monitoring, which may include access to, ordering, or 
     performing laboratory assessments, and evaluating the 
     response of the patient to therapy, including safety and 
     effectiveness;
       ``(5) performing an initial comprehensive medication review 
     to identify, resolve, and prevent medication-related 
     problems, including adverse drug events, quarterly targeted 
     medication reviews for ongoing monitoring, and additional 
     followup interventions on a schedule developed 
     collaboratively with the prescriber;
       ``(6) documenting the care delivered and communicating 
     essential information about such care, including a summary of 
     the medication review, and the recommendations of the 
     pharmacist to other appropriate health care providers of the 
     patient in a timely fashion;
       ``(7) providing education and training designed to enhance 
     the understanding and appropriate use of the medications by 
     the patient, caregiver, and other authorized representative;
       ``(8) providing information, support services, and 
     resources and strategies designed to enhance patient 
     adherence with therapeutic regimens;
       ``(9) coordinating and integrating MTM services within the 
     broader health care management services provided to the 
     patient; and
       ``(10) such other patient care services allowed under 
     pharmacist scopes of practice in use in other Federal 
     programs that have implemented MTM services.
       ``(d) Targeted Individuals.--MTM services provided by 
     licensed pharmacists under a grant or contract awarded under 
     subsection (a) shall be offered to targeted individuals who--
       ``(1) take 4 or more prescribed medications (including 
     over-the-counter medications and dietary supplements);
       ``(2) take any `high risk' medications;
       ``(3) have 2 or more chronic diseases, as identified by the 
     Secretary; or
       ``(4) have undergone a transition of care, or other 
     factors, as determined by the Secretary, that are likely to 
     create a high risk of medication-related problems.
       ``(e) Consultation With Experts.--In designing and 
     implementing MTM services provided under grants or contracts 
     awarded under subsection (a), the Secretary shall consult 
     with Federal, State, private, public-private, and academic 
     entities, pharmacy and pharmacist organizations, health care 
     organizations, consumer advocates, chronic disease groups, 
     and other stakeholders involved with the research, 
     dissemination, and implementation of pharmacist-delivered MTM 
     services, as the Secretary determines appropriate. The 
     Secretary, in collaboration with this group, shall determine 
     whether it is possible to incorporate rapid cycle process 
     improvement concepts in use in other Federal programs that 
     have implemented MTM services.
       ``(f) Reporting to the Secretary.--An entity that receives 
     a grant or contract under subsection (a) shall submit to the 
     Secretary a report that describes and evaluates, as requested 
     by the Secretary, the activities carried out under subsection 
     (c), including quality measures endorsed by the entity with a 
     contract under section 1890 of the Social Security Act, as 
     determined by the Secretary.
       ``(g) Evaluation and Report.--The Secretary shall submit to 
     the relevant committees of Congress a report which shall--
       ``(1) assess the clinical effectiveness of pharmacist-
     provided services under the MTM services program, as compared 
     to usual care, including an evaluation of whether enrollees 
     maintained better health with fewer hospitalizations and 
     emergency room visits than similar patients not enrolled in 
     the program;
       ``(2) assess changes in overall health care resource use by 
     targeted individuals;
       ``(3) assess patient and prescriber satisfaction with MTM 
     services;
       ``(4) assess the impact of patient-cost sharing 
     requirements on medication adherence and recommendations for 
     modifications;
       ``(5) identify and evaluate other factors that may impact 
     clinical and economic outcomes, including demographic 
     characteristics, clinical characteristics, and health 
     services use of the patient, as well as characteristics of 
     the regimen, pharmacy benefit, and MTM services provided; and
       ``(6) evaluate the extent to which participating 
     pharmacists who maintain a dispensing role have a conflict of 
     interest in the provision of MTM services, and if such 
     conflict is found, provide recommendations on how such a 
     conflict might be appropriately addressed.
       ``(h) Grants or Contracts To Fund Development of 
     Performance Measures.--The Secretary may, through the quality 
     measure development program under section 931 of the Public 
     Health Service Act, award grants or contracts to eligible 
     entities for the purpose of funding the development of 
     performance measures that assess the use and effectiveness of 
     medication therapy management services.''.

     SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYSTEMS 
                   FOR EMERGENCY CARE.

       (a) In General.--Title XII of the Public Health Service Act 
     (42 U.S.C. 300d et seq.) is amended--
       (1) in section 1203--
       (A) in the section heading, by inserting ``FOR TRAUMA 
     SYSTEMS'' after ``GRANTS''; and
       (B) in subsection (a), by striking ``Administrator of the 
     Health Resources and Services Administration'' and inserting 
     ``Assistant Secretary for Preparedness and Response'';
       (2) by inserting after section 1203 the following:

     ``SEC. 1204. COMPETITIVE GRANTS FOR REGIONALIZED SYSTEMS FOR 
                   EMERGENCY CARE RESPONSE.

       ``(a) In General.--The Secretary, acting through the 
     Assistant Secretary for Preparedness and Response, shall 
     award not fewer than 4 multiyear contracts or competitive 
     grants to eligible entities to support pilot projects that 
     design, implement, and evaluate innovative models of 
     regionalized, comprehensive, and accountable emergency care 
     and trauma systems.
       ``(b) Eligible Entity; Region.--In this section:
       ``(1) Eligible entity.--The term `eligible entity' means--
       ``(A) a State or a partnership of 1 or more States and 1 or 
     more local governments; or
       ``(B) an Indian tribe (as defined in section 4 of the 
     Indian Health Care Improvement Act) or a partnership of 1 or 
     more Indian tribes.
       ``(2) Region.--The term `region' means an area within a 
     State, an area that lies within multiple States, or a similar 
     area (such as a multicounty area), as determined by the 
     Secretary.
       ``(3) Emergency services.--The term `emergency services' 
     includes acute, prehospital, and trauma care.
       ``(c) Pilot Projects.--The Secretary shall award a contract 
     or grant under subsection (a) to an eligible entity that 
     proposes a pilot project to design, implement, and evaluate 
     an emergency medical and trauma system that--

[[Page 4310]]

       ``(1) coordinates with public health and safety services, 
     emergency medical services, medical facilities, trauma 
     centers, and other entities in a region to develop an 
     approach to emergency medical and trauma system access 
     throughout the region, including 9-1-1 Public Safety 
     Answering Points and emergency medical dispatch;
       ``(2) includes a mechanism, such as a regional medical 
     direction or transport communications system, that operates 
     throughout the region to ensure that the patient is taken to 
     the medically appropriate facility (whether an initial 
     facility or a higher-level facility) in a timely fashion;
       ``(3) allows for the tracking of prehospital and hospital 
     resources, including inpatient bed capacity, emergency 
     department capacity, trauma center capacity, on-call 
     specialist coverage, ambulance diversion status, and the 
     coordination of such tracking with regional communications 
     and hospital destination decisions; and
       ``(4) includes a consistent region-wide prehospital, 
     hospital, and interfacility data management system that--
       ``(A) submits data to the National EMS Information System, 
     the National Trauma Data Bank, and others;
       ``(B) reports data to appropriate Federal and State 
     databanks and registries; and
       ``(C) contains information sufficient to evaluate key 
     elements of prehospital care, hospital destination decisions, 
     including initial hospital and interfacility decisions, and 
     relevant health outcomes of hospital care.
       ``(d) Application.--
       ``(1) In general.--An eligible entity that seeks a contract 
     or grant described in subsection (a) shall submit to the 
     Secretary an application at such time and in such manner as 
     the Secretary may require.
       ``(2) Application information.--Each application shall 
     include--
       ``(A) an assurance from the eligible entity that the 
     proposed system--
       ``(i) has been coordinated with the applicable State Office 
     of Emergency Medical Services (or equivalent State office);
       ``(ii) includes consistent indirect and direct medical 
     oversight of prehospital, hospital, and interfacility 
     transport throughout the region;
       ``(iii) coordinates prehospital treatment and triage, 
     hospital destination, and interfacility transport throughout 
     the region;
       ``(iv) includes a categorization or designation system for 
     special medical facilities throughout the region that is 
     integrated with transport and destination protocols;
       ``(v) includes a regional medical direction, patient 
     tracking, and resource allocation system that supports day-
     to-day emergency care and surge capacity and is integrated 
     with other components of the national and State emergency 
     preparedness system; and
       ``(vi) addresses pediatric concerns related to integration, 
     planning, preparedness, and coordination of emergency medical 
     services for infants, children and adolescents; and
       ``(B) such other information as the Secretary may require.
       ``(e) Requirement of Matching Funds.--
       ``(1) In general.--The Secretary may not make a grant under 
     this section unless the State (or consortia of States) 
     involved agrees, with respect to the costs to be incurred by 
     the State (or consortia) in carrying out the purpose for 
     which such grant was made, to make available non-Federal 
     contributions (in cash or in kind under paragraph (2)) toward 
     such costs in an amount equal to not less than $1 for each $3 
     of Federal funds provided in the grant. Such contributions 
     may be made directly or through donations from public or 
     private entities.
       ``(2) Non-federal contributions.--Non-Federal contributions 
     required in paragraph (1) may be in cash or in kind, fairly 
     evaluated, including equipment or services (and excluding 
     indirect or overhead costs). Amounts provided by the Federal 
     Government, or services assisted or subsidized to any 
     significant extent by the Federal Government, may not be 
     included in determining the amount of such non-Federal 
     contributions.
       ``(f) Priority.--The Secretary shall give priority for the 
     award of the contracts or grants described in subsection (a) 
     to any eligible entity that serves a population in a 
     medically underserved area (as defined in section 330(b)(3)).
       ``(g) Report.--Not later than 90 days after the completion 
     of a pilot project under subsection (a), the recipient of 
     such contract or grant described in shall submit to the 
     Secretary a report containing the results of an evaluation of 
     the program, including an identification of--
       ``(1) the impact of the regional, accountable emergency 
     care and trauma system on patient health outcomes for various 
     critical care categories, such as trauma, stroke, cardiac 
     emergencies, neurological emergencies, and pediatric 
     emergencies;
       ``(2) the system characteristics that contribute to the 
     effectiveness and efficiency of the program (or lack 
     thereof);
       ``(3) methods of assuring the long-term financial 
     sustainability of the emergency care and trauma system;
       ``(4) the State and local legislation necessary to 
     implement and to maintain the system;
       ``(5) the barriers to developing regionalized, accountable 
     emergency care and trauma systems, as well as the methods to 
     overcome such barriers; and
       ``(6) recommendations on the utilization of available 
     funding for future regionalization efforts.
       ``(h) Dissemination of Findings.--The Secretary shall, as 
     appropriate, disseminate to the public and to the appropriate 
     Committees of the Congress, the information contained in a 
     report made under subsection (g).''; and
       (3) in section 1232--
       (A) in subsection (a), by striking ``appropriated'' and all 
     that follows through the period at the end and inserting 
     ``appropriated $24,000,000 for each of fiscal years 2010 
     through 2014.''; and
       (B) by inserting after subsection (c) the following:
       ``(d) Authority.--For the purpose of carrying out parts A 
     through C, beginning on the date of enactment of the Patient 
     Protection and Affordable Care Act, the Secretary shall 
     transfer authority in administering grants and related 
     authorities under such parts from the Administrator of the 
     Health Resources and Services Administration to the Assistant 
     Secretary for Preparedness and Response.''.
       (b) Support for Emergency Medicine Research.--Part H of 
     title IV of the Public Health Service Act (42 U.S.C. 289 et 
     seq.) is amended by inserting after the section 498C the 
     following:

     ``SEC. 498D. SUPPORT FOR EMERGENCY MEDICINE RESEARCH.

       ``(a) Emergency Medical Research.--The Secretary shall 
     support Federal programs administered by the National 
     Institutes of Health, the Agency for Healthcare Research and 
     Quality, the Health Resources and Services Administration, 
     the Centers for Disease Control and Prevention, and other 
     agencies involved in improving the emergency care system to 
     expand and accelerate research in emergency medical care 
     systems and emergency medicine, including--
       ``(1) the basic science of emergency medicine;
       ``(2) the model of service delivery and the components of 
     such models that contribute to enhanced patient health 
     outcomes;
       ``(3) the translation of basic scientific research into 
     improved practice; and
       ``(4) the development of timely and efficient delivery of 
     health services.
       ``(b) Pediatric Emergency Medical Research.--The Secretary 
     shall support Federal programs administered by the National 
     Institutes of Health, the Agency for Healthcare Research and 
     Quality, the Health Resources and Services Administration, 
     the Centers for Disease Control and Prevention, and other 
     agencies to coordinate and expand research in pediatric 
     emergency medical care systems and pediatric emergency 
     medicine, including--
       ``(1) an examination of the gaps and opportunities in 
     pediatric emergency care research and a strategy for the 
     optimal organization and funding of such research;
       ``(2) the role of pediatric emergency services as an 
     integrated component of the overall health system;
       ``(3) system-wide pediatric emergency care planning, 
     preparedness, coordination, and funding;
       ``(4) pediatric training in professional education; and
       ``(5) research in pediatric emergency care, specifically on 
     the efficacy, safety, and health outcomes of medications used 
     for infants, children, and adolescents in emergency care 
     settings in order to improve patient safety.
       ``(c) Impact Research.--The Secretary shall support 
     research to determine the estimated economic impact of, and 
     savings that result from, the implementation of coordinated 
     emergency care systems.
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section such 
     sums as may be necessary for each of fiscal years 2010 
     through 2014.''.

     SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY.

       (a) Trauma Care Centers.--
       (1) Grants for trauma care centers.--Section 1241 of the 
     Public Health Service Act (42 U.S.C. 300d-41) is amended by 
     striking subsections (a) and (b) and inserting the following:
       ``(a) In General.--The Secretary shall establish 3 programs 
     to award grants to qualified public, nonprofit Indian Health 
     Service, Indian tribal, and urban Indian trauma centers--
       ``(1) to assist in defraying substantial uncompensated care 
     costs;
       ``(2) to further the core missions of such trauma centers, 
     including by addressing costs associated with patient 
     stabilization and transfer, trauma education and outreach, 
     coordination with local and regional trauma systems, 
     essential personnel and other fixed costs, and expenses 
     associated with employee and non-employee physician services; 
     and
       ``(3) to provide emergency relief to ensure the continued 
     and future availability of trauma services.
       ``(b) Minimum Qualifications of Trauma Centers.--
       ``(1) Participation in trauma care system operating under 
     certain professional guidelines.--Except as provided in 
     paragraph (2), the Secretary may not award a grant to a 
     trauma center under subsection (a) unless the trauma center 
     is a participant in a trauma system that substantially 
     complies with section 1213.
       ``(2) Exemption.--Paragraph (1) shall not apply to trauma 
     centers that are located in States with no existing trauma 
     care system.
       ``(3) Qualification for substantial uncompensated care 
     costs.--The Secretary shall award substantial uncompensated 
     care grants under subsection (a)(1) only to trauma centers 
     meeting at least 1 of the criteria in 1 of the following 3 
     categories:
       ``(A) Category a.--The criteria for category A are as 
     follows:
       ``(i) At least 40 percent of the visits in the emergency 
     department of the hospital in which

[[Page 4311]]

     the trauma center is located were charity or self-pay 
     patients.
       ``(ii) At least 50 percent of the visits in such emergency 
     department were Medicaid (under title XIX of the Social 
     Security Act (42 U.S.C. 1396 et seq.)) and charity and self-
     pay patients combined.
       ``(B) Category b.--The criteria for category B are as 
     follows:
       ``(i) At least 35 percent of the visits in the emergency 
     department were charity or self-pay patients.
       ``(ii) At least 50 percent of the visits in the emergency 
     department were Medicaid and charity and self-pay patients 
     combined.
       ``(C) Category c.--The criteria for category C are as 
     follows:
       ``(i) At least 20 percent of the visits in the emergency 
     department were charity or self-pay patients.
       ``(ii) At least 30 percent of the visits in the emergency 
     department were Medicaid and charity and self-pay patients 
     combined.
       ``(4) Trauma centers in 1115 waiver states.--
     Notwithstanding paragraph (3), the Secretary may award a 
     substantial uncompensated care grant to a trauma center under 
     subsection (a)(1) if the trauma center qualifies for funds 
     under a Low Income Pool or Safety Net Care Pool established 
     through a waiver approved under section 1115 of the Social 
     Security Act (42 U.S.C. 1315).
       ``(5) Designation.--The Secretary may not award a grant to 
     a trauma center unless such trauma center is verified by the 
     American College of Surgeons or designated by an equivalent 
     State or local agency.
       ``(c) Additional Requirements.--The Secretary may not award 
     a grant to a trauma center under subsection (a)(1) unless 
     such trauma center--
       ``(1) submits to the Secretary a plan satisfactory to the 
     Secretary that demonstrates a continued commitment to serving 
     trauma patients regardless of their ability to pay; and
       ``(2) has policies in place to assist patients who cannot 
     pay for part or all of the care they receive, including a 
     sliding fee scale, and to ensure fair billing and collection 
     practices.''.
       (2) Considerations in making grants.--Section 1242 of the 
     Public Health Service Act (42 U.S.C. 300d-42) is amended by 
     striking subsections (a) and (b) and inserting the following:
       ``(a) Substantial Uncompensated Care Awards.--
       ``(1) In general.--The Secretary shall establish an award 
     basis for each eligible trauma center for grants under 
     section 1241(a)(1) according to the percentage described in 
     paragraph (2), subject to the requirements of section 
     1241(b)(3).
       ``(2) Percentages.--The applicable percentages are as 
     follows:
       ``(A) With respect to a category A trauma center, 100 
     percent of the uncompensated care costs.
       ``(B) With respect to a category B trauma center, not more 
     than 75 percent of the uncompensated care costs.
       ``(C) With respect to a category C trauma center, not more 
     than 50 percent of the uncompensated care costs.
       ``(b) Core Mission Awards.--
       ``(1) In general.--In awarding grants under section 
     1241(a)(2), the Secretary shall--
       ``(A) reserve 25 percent of the amount allocated for core 
     mission awards for Level III and Level IV trauma centers; and
       ``(B) reserve 25 percent of the amount allocated for core 
     mission awards for large urban Level I and II trauma 
     centers--
       ``(i) that have at least 1 graduate medical education 
     fellowship in trauma or trauma related specialties for which 
     demand is exceeding supply;
       ``(ii) for which--

       ``(I) annual uncompensated care costs exceed $10,000,000; 
     or
       ``(II) at least 20 percent of emergency department visits 
     are charity or self-pay or Medicaid patients; and

       ``(iii) that are not eligible for substantial uncompensated 
     care awards under section 1241(a)(1).
       ``(c) Emergency Awards.--In awarding grants under section 
     1241(a)(3), the Secretary shall--
       ``(1) give preference to any application submitted by a 
     trauma center that provides trauma care in a geographic area 
     in which the availability of trauma care has significantly 
     decreased or will significantly decrease if the center is 
     forced to close or downgrade service or growth in demand for 
     trauma services exceeds capacity; and
       ``(2) reallocate any emergency awards funds not obligated 
     due to insufficient, or a lack of qualified, applications to 
     the significant uncompensated care award program.''.
       (3) Certain agreements.--Section 1243 of the Public Health 
     Service Act (42 U.S.C. 300d-43) is amended by striking 
     subsections (a), (b), and (c) and inserting the following:
       ``(a) Maintenance of Financial Support.--The Secretary may 
     require a trauma center receiving a grant under section 
     1241(a) to maintain access to trauma services at comparable 
     levels to the prior year during the grant period.
       ``(b) Trauma Care Registry.--The Secretary may require the 
     trauma center receiving a grant under section 1241(a) to 
     provide data to a national and centralized registry of trauma 
     cases, in accordance with guidelines developed by the 
     American College of Surgeons, and as the Secretary may 
     otherwise require.''.
       (4) General provisions.--Section 1244 of the Public Health 
     Service Act (42 U.S.C. 300d-44) is amended by striking 
     subsections (a), (b), and (c) and inserting the following:
       ``(a) Application.--The Secretary may not award a grant to 
     a trauma center under section 1241(a) unless such center 
     submits an application for the grant to the Secretary and the 
     application is in such form, is made in such manner, and 
     contains such agreements, assurances, and information as the 
     Secretary determines to be necessary to carry out this part.
       ``(b) Limitation on Duration of Support.--The period during 
     which a trauma center receives payments under a grant under 
     section 1241(a)(3) shall be for 3 fiscal years, except that 
     the Secretary may waive such requirement for a center and 
     authorize such center to receive such payments for 1 
     additional fiscal year.
       ``(c) Limitation on Amount of Grant.--Notwithstanding 
     section 1242(a), a grant under section 1241 may not be made 
     in an amount exceeding $2,000,000 for each fiscal year.
       ``(d) Eligibility.--Except as provided in section 
     1242(b)(1)(B)(iii), acquisition of, or eligibility for, a 
     grant under section 1241(a) shall not preclude a trauma 
     center from being eligible for other grants described in such 
     section.
       ``(e) Funding Distribution.--Of the total amount 
     appropriated for a fiscal year under section 1245, 70 percent 
     shall be used for substantial uncompensated care awards under 
     section 1241(a)(1), 20 percent shall be used for core mission 
     awards under section 1241(a)(2), and 10 percent shall be used 
     for emergency awards under section 1241(a)(3).
       ``(f) Minimum Allowance.--Notwithstanding subsection (e), 
     if the amount appropriated for a fiscal year under section 
     1245 is less than $25,000,000, all available funding for such 
     fiscal year shall be used for substantial uncompensated care 
     awards under section 1241(a)(1).
       ``(g) Substantial Uncompensated Care Award Distribution and 
     Proportional Share.--Notwithstanding section 1242(a), of the 
     amount appropriated for substantial uncompensated care grants 
     for a fiscal year, the Secretary shall--
       ``(1) make available--
       ``(A) 50 percent of such funds for category A trauma center 
     grantees;
       ``(B) 35 percent of such funds for category B trauma center 
     grantees; and
       ``(C) 15 percent of such funds for category C trauma center 
     grantees; and
       ``(2) provide available funds within each category in a 
     manner proportional to the award basis specified in section 
     1242(a)(2) to each eligible trauma center.
       ``(h) Report.--Beginning 2 years after the date of 
     enactment of the Patient Protection and Affordable Care Act, 
     and every 2 years thereafter, the Secretary shall biennially 
     report to Congress regarding the status of the grants made 
     under section 1241 and on the overall financial stability of 
     trauma centers.''.
       (5) Authorization of appropriations.--Section 1245 of the 
     Public Health Service Act (42 U.S.C. 300d-45) is amended to 
     read as follows:

     ``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.

       ``For the purpose of carrying out this part, there are 
     authorized to be appropriated $100,000,000 for fiscal year 
     2009, and such sums as may be necessary for each of fiscal 
     years 2010 through 2015. Such authorization of appropriations 
     is in addition to any other authorization of appropriations 
     or amounts that are available for such purpose.''.
       (6) Definition.--Part D of title XII of the Public Health 
     Service Act (42 U.S.C. 300d-41 et seq.) is amended by adding 
     at the end the following:

     ``SEC. 1246. DEFINITION.

       ``In this part, the term `uncompensated care costs' means 
     unreimbursed costs from serving self-pay, charity, or 
     Medicaid patients, without regard to payment under section 
     1923 of the Social Security Act, all of which are 
     attributable to emergency care and trauma care, including 
     costs related to subsequent inpatient admissions to the 
     hospital.''.
       (b) Trauma Service Availability.--Title XII of the Public 
     Health Service Act (42 U.S.C. 300d et seq.) is amended by 
     adding at the end the following:

                 ``PART H--TRAUMA SERVICE AVAILABILITY

     ``SEC. 1281. GRANTS TO STATES.

       ``(a) Establishment.--To promote universal access to trauma 
     care services provided by trauma centers and trauma-related 
     physician specialties, the Secretary shall provide funding to 
     States to enable such States to award grants to eligible 
     entities for the purposes described in this section.
       ``(b) Awarding of Grants by States.--Each State may award 
     grants to eligible entities within the State for the purposes 
     described in subparagraph (d).
       ``(c) Eligibility.--
       ``(1) In general.--To be eligible to receive a grant under 
     subsection (b) an entity shall--
       ``(A) be--
       ``(i) a public or nonprofit trauma center or consortium 
     thereof that meets that requirements of paragraphs (1), (2), 
     and (5) of section 1241(b);
       ``(ii) a safety net public or nonprofit trauma center that 
     meets the requirements of paragraphs (1) through (5) of 
     section 1241(b); or
       ``(iii) a hospital in an underserved area (as defined by 
     the State) that seeks to establish new trauma services; and
       ``(B) submit to the State an application at such time, in 
     such manner, and containing such information as the State may 
     require.
       ``(2) Limitation.--A State shall use at least 40 percent of 
     the amount available to the State under this part for a 
     fiscal year to award grants to safety net trauma centers 
     described in paragraph (1)(A)(ii).
       ``(d) Use of Funds.--The recipient of a grant under 
     subsection (b) shall carry out 1 or more of

[[Page 4312]]

     the following activities consistent with subsection (b):
       ``(1) Providing trauma centers with funding to support 
     physician compensation in trauma-related physician 
     specialties where shortages exist in the region involved, 
     with priority provided to safety net trauma centers described 
     in subsection (c)(1)(A)(ii).
       ``(2) Providing for individual safety net trauma center 
     fiscal stability and costs related to having service that is 
     available 24 hours a day, 7 days a week, with priority 
     provided to safety net trauma centers described in subsection 
     (c)(1)(A)(ii) located in urban, border, and rural areas.
       ``(3) Reducing trauma center overcrowding at specific 
     trauma centers related to throughput of trauma patients.
       ``(4) Establishing new trauma services in underserved areas 
     as defined by the State.
       ``(5) Enhancing collaboration between trauma centers and 
     other hospitals and emergency medical services personnel 
     related to trauma service availability.
       ``(6) Making capital improvements to enhance access and 
     expedite trauma care, including providing helipads and 
     associated safety infrastructure.
       ``(7) Enhancing trauma surge capacity at specific trauma 
     centers.
       ``(8) Ensuring expedient receipt of trauma patients 
     transported by ground or air to the appropriate trauma 
     center.
       ``(9) Enhancing interstate trauma center collaboration.
       ``(e) Limitation.--
       ``(1) In general.--A State may use not more than 20 percent 
     of the amount available to the State under this part for a 
     fiscal year for administrative costs associated with awarding 
     grants and related costs.
       ``(2) Maintenance of effort.--The Secretary may not provide 
     funding to a State under this part unless the State agrees 
     that such funds will be used to supplement and not supplant 
     State funding otherwise available for the activities and 
     costs described in this part.
       ``(f) Distribution of Funds.--The following shall apply 
     with respect to grants provided in this part:
       ``(1) Less than $10,000,000.--If the amount of 
     appropriations for this part in a fiscal year is less than 
     $10,000,000, the Secretary shall divide such funding evenly 
     among only those States that have 1 or more trauma centers 
     eligible for funding under section 1241(b)(3)(A).
       ``(2) Less than $20,000,000.--If the amount of 
     appropriations in a fiscal year is less than $20,000,000, the 
     Secretary shall divide such funding evenly among only those 
     States that have 1 or more trauma centers eligible for 
     funding under subparagraphs (A) and (B) of section 
     1241(b)(3).
       ``(3) Less than $30,000,000.--If the amount of 
     appropriations for this part in a fiscal year is less than 
     $30,000,000, the Secretary shall divide such funding evenly 
     among only those States that have 1 or more trauma centers 
     eligible for funding under section 1241(b)(3).
       ``(4) $30,000,000 or more.--If the amount of appropriations 
     for this part in a fiscal year is $30,000,000 or more, the 
     Secretary shall divide such funding evenly among all States.

     ``SEC. 1282. AUTHORIZATION OF APPROPRIATIONS.

       ``For the purpose of carrying out this part, there is 
     authorized to be appropriated $100,000,000 for each of fiscal 
     years 2010 through 2015.''.

     SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING.

       Part D of title IX of the Public Health Service Act, as 
     amended by section 3503, is further amended by adding at the 
     end the following:

     ``SEC. 936. PROGRAM TO FACILITATE SHARED DECISIONMAKING.

       ``(a) Purpose.--The purpose of this section is to 
     facilitate collaborative processes between patients, 
     caregivers or authorized representatives, and clinicians that 
     engages the patient, caregiver or authorized representative 
     in decisionmaking, provides patients, caregivers or 
     authorized representatives with information about trade-offs 
     among treatment options, and facilitates the incorporation of 
     patient preferences and values into the medical plan.
       ``(b) Definitions.--In this section:
       ``(1) Patient decision aid.--The term `patient decision 
     aid' means an educational tool that helps patients, 
     caregivers or authorized representatives understand and 
     communicate their beliefs and preferences related to their 
     treatment options, and to decide with their health care 
     provider what treatments are best for them based on their 
     treatment options, scientific evidence, circumstances, 
     beliefs, and preferences.
       ``(2) Preference sensitive care.--The term `preference 
     sensitive care' means medical care for which the clinical 
     evidence does not clearly support one treatment option such 
     that the appropriate course of treatment depends on the 
     values of the patient or the preferences of the patient, 
     caregivers or authorized representatives regarding the 
     benefits, harms and scientific evidence for each treatment 
     option, the use of such care should depend on the informed 
     patient choice among clinically appropriate treatment 
     options.
       ``(c) Establishment of Independent Standards for Patient 
     Decision Aids for Preference Sensitive Care.--
       ``(1) Contract with entity to establish standards and 
     certify patient decision aids.--
       ``(A) In general.--For purposes of supporting consensus-
     based standards for patient decision aids for preference 
     sensitive care and a certification process for patient 
     decision aids for use in the Federal health programs and by 
     other interested parties, the Secretary shall have in effect 
     a contract with the entity with a contract under section 1890 
     of the Social Security Act. Such contract shall provide that 
     the entity perform the duties described in paragraph (2).
       ``(B) Timing for first contract.--As soon as practicable 
     after the date of the enactment of this section, the 
     Secretary shall enter into the first contract under 
     subparagraph (A).
       ``(C) Period of contract.--A contract under subparagraph 
     (A) shall be for a period of 18 months (except such contract 
     may be renewed after a subsequent bidding process).
       ``(2) Duties.--The following duties are described in this 
     paragraph:
       ``(A) Develop and identify standards for patient decision 
     aids.--The entity shall synthesize evidence and convene a 
     broad range of experts and key stakeholders to develop and 
     identify consensus-based standards to evaluate patient 
     decision aids for preference sensitive care.
       ``(B) Endorse patient decision aids.--The entity shall 
     review patient decision aids and develop a certification 
     process whether patient decision aids meet the standards 
     developed and identified under subparagraph (A). The entity 
     shall give priority to the review and certification of 
     patient decision aids for preference sensitive care.
       ``(d) Program To Develop, Update and Patient Decision Aids 
     To Assist Health Care Providers and Patients.--
       ``(1) In general.--The Secretary, acting through the 
     Director, and in coordination with heads of other relevant 
     agencies, such as the Director of the Centers for Disease 
     Control and Prevention and the Director of the National 
     Institutes of Health, shall establish a program to award 
     grants or contracts--
       ``(A) to develop, update, and produce patient decision aids 
     for preference sensitive care to assist health care providers 
     in educating patients, caregivers, and authorized 
     representatives concerning the relative safety, relative 
     effectiveness (including possible health outcomes and impact 
     on functional status), and relative cost of treatment or, 
     where appropriate, palliative care options;
       ``(B) to test such materials to ensure such materials are 
     balanced and evidence based in aiding health care providers 
     and patients, caregivers, and authorized representatives to 
     make informed decisions about patient care and can be easily 
     incorporated into a broad array of practice settings; and
       ``(C) to educate providers on the use of such materials, 
     including through academic curricula.
       ``(2) Requirements for patient decision aids.--Patient 
     decision aids developed and produced pursuant to a grant or 
     contract under paragraph (1)--
       ``(A) shall be designed to engage patients, caregivers, and 
     authorized representatives in informed decisionmaking with 
     health care providers;
       ``(B) shall present up-to-date clinical evidence about the 
     risks and benefits of treatment options in a form and manner 
     that is age-appropriate and can be adapted for patients, 
     caregivers, and authorized representatives from a variety of 
     cultural and educational backgrounds to reflect the varying 
     needs of consumers and diverse levels of health literacy;
       ``(C) shall, where appropriate, explain why there is a lack 
     of evidence to support one treatment option over another; and
       ``(D) shall address health care decisions across the age 
     span, including those affecting vulnerable populations 
     including children.
       ``(3) Distribution.--The Director shall ensure that patient 
     decision aids produced with grants or contracts under this 
     section are available to the public.
       ``(4) Nonduplication of efforts.--The Director shall ensure 
     that the activities under this section of the Agency and 
     other agencies, including the Centers for Disease Control and 
     Prevention and the National Institutes of Health, are free of 
     unnecessary duplication of effort.
       ``(e) Grants To Support Shared Decisionmaking 
     Implementation.--
       ``(1) In general.--The Secretary shall establish a program 
     to provide for the phased-in development, implementation, and 
     evaluation of shared decisionmaking using patient decision 
     aids to meet the objective of improving the understanding of 
     patients of their medical treatment options.
       ``(2) Shared decisionmaking resource centers.--
       ``(A) In general.--The Secretary shall provide grants for 
     the establishment and support of Shared Decisionmaking 
     Resource Centers (referred to in this subsection as 
     `Centers') to provide technical assistance to providers and 
     to develop and disseminate best practices and other 
     information to support and accelerate adoption, 
     implementation, and effective use of patient decision aids 
     and shared decisionmaking by providers.
       ``(B) Objectives.--The objective of a Center is to enhance 
     and promote the adoption of patient decision aids and shared 
     decisionmaking through--
       ``(i) providing assistance to eligible providers with the 
     implementation and effective use of, and training on, patient 
     decision aids; and
       ``(ii) the dissemination of best practices and research on 
     the implementation and effective use of patient decision 
     aids.
       ``(3) Shared decisionmaking participation grants.--

[[Page 4313]]

       ``(A) In general.--The Secretary shall provide grants to 
     health care providers for the development and implementation 
     of shared decisionmaking techniques and to assess the use of 
     such techniques.
       ``(B) Preference.--In order to facilitate the use of best 
     practices, the Secretary shall provide a preference in making 
     grants under this subsection to health care providers who 
     participate in training by Shared Decisionmaking Resource 
     Centers or comparable training.
       ``(C) Limitation.--Funds under this paragraph shall not be 
     used to purchase or implement use of patient decision aids 
     other than those certified under the process identified in 
     subsection (c).
       ``(4) Guidance.--The Secretary may issue guidance to 
     eligible grantees under this subsection on the use of patient 
     decision aids.
       ``(f) Funding.--For purposes of carrying out this section 
     there are authorized to be appropriated such sums as may be 
     necessary for fiscal year 2010 and each subsequent fiscal 
     year.''.

     SEC. 3507. PRESENTATION OF PRESCRIPTION DRUG BENEFIT AND RISK 
                   INFORMATION.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Commissioner of Food and Drugs, shall determine 
     whether the addition of quantitative summaries of the 
     benefits and risks of prescription drugs in a standardized 
     format (such as a table or drug facts box) to the promotional 
     labeling or print advertising of such drugs would improve 
     health care decisionmaking by clinicians and patients and 
     consumers.
       (b) Review and Consultation.--In making the determination 
     under subsection (a), the Secretary shall review all 
     available scientific evidence and research on decisionmaking 
     and social and cognitive psychology and consult with drug 
     manufacturers, clinicians, patients and consumers, experts in 
     health literacy, representatives of racial and ethnic 
     minorities, and experts in women's and pediatric health.
       (c) Report.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary shall submit to Congress 
     a report that provides--
       (1) the determination by the Secretary under subsection 
     (a); and
       (2) the reasoning and analysis underlying that 
     determination.
       (d) Authority.--If the Secretary determines under 
     subsection (a) that the addition of quantitative summaries of 
     the benefits and risks of prescription drugs in a 
     standardized format (such as a table or drug facts box) to 
     the promotional labeling or print advertising of such drugs 
     would improve health care decisionmaking by clinicians and 
     patients and consumers, then the Secretary, not later than 3 
     years after the date of submission of the report under 
     subsection (c), shall promulgate proposed regulations as 
     necessary to implement such format.
       (e) Clarification.--Nothing in this section shall be 
     construed to restrict the existing authorities of the 
     Secretary with respect to benefit and risk information.

     SEC. 3508. DEMONSTRATION PROGRAM TO INTEGRATE QUALITY 
                   IMPROVEMENT AND PATIENT SAFETY TRAINING INTO 
                   CLINICAL EDUCATION OF HEALTH PROFESSIONALS.

       (a) In General.--The Secretary may award grants to eligible 
     entities or consortia under this section to carry out 
     demonstration projects to develop and implement academic 
     curricula that integrates quality improvement and patient 
     safety in the clinical education of health professionals. 
     Such awards shall be made on a competitive basis and pursuant 
     to peer review.
       (b) Eligibility.--To be eligible to receive a grant under 
     subsection (a), an entity or consortium shall--
       (1) submit to the Secretary an application at such time, in 
     such manner, and containing such information as the Secretary 
     may require;
       (2) be or include--
       (A) a health professions school;
       (B) a school of public health;
       (C) a school of social work;
       (D) a school of nursing;
       (E) a school of pharmacy;
       (F) an institution with a graduate medical education 
     program; or
       (G) a school of health care administration;
       (3) collaborate in the development of curricula described 
     in subsection (a) with an organization that accredits such 
     school or institution;
       (4) provide for the collection of data regarding the 
     effectiveness of the demonstration project; and
       (5) provide matching funds in accordance with subsection 
     (c).
       (c) Matching Funds.--
       (1) In general.--The Secretary may award a grant to an 
     entity or consortium under this section only if the entity or 
     consortium agrees to make available non-Federal contributions 
     toward the costs of the program to be funded under the grant 
     in an amount that is not less than $1 for each $5 of Federal 
     funds provided under the grant.
       (2) Determination of amount contributed.--Non-Federal 
     contributions under paragraph (1) may be in cash or in-kind, 
     fairly evaluated, including equipment or services. Amounts 
     provided by the Federal Government, or services assisted or 
     subsidized to any significant extent by the Federal 
     Government, may not be included in determining the amount of 
     such contributions.
       (d) Evaluation.--The Secretary shall take such action as 
     may be necessary to evaluate the projects funded under this 
     section and publish, make publicly available, and disseminate 
     the results of such evaluations on as wide a basis as is 
     practicable.
       (e) Reports.--Not later than 2 years after the date of 
     enactment of this section, and annually thereafter, the 
     Secretary shall submit to the Committee on Health, Education, 
     Labor, and Pensions and the Committee on Finance of the 
     Senate and the Committee on Energy and Commerce and the 
     Committee on Ways and Means of the House of Representatives a 
     report that--
       (1) describes the specific projects supported under this 
     section; and
       (2) contains recommendations for Congress based on the 
     evaluation conducted under subsection (d).

     SEC. 3509. IMPROVING WOMEN'S HEALTH.

       (a) Health and Human Services Office on Women's Health.--
       (1) Establishment.--Part A of title II of the Public Health 
     Service Act (42 U.S.C. 202 et seq.) is amended by adding at 
     the end the following:

     ``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S 
                   HEALTH.

       ``(a) Establishment of Office.--There is established within 
     the Office of the Secretary, an Office on Women's Health 
     (referred to in this section as the `Office'). The Office 
     shall be headed by a Deputy Assistant Secretary for Women's 
     Health who may report to the Secretary.
       ``(b) Duties.--The Secretary, acting through the Office, 
     with respect to the health concerns of women, shall--
       ``(1) establish short-range and long-range goals and 
     objectives within the Department of Health and Human Services 
     and, as relevant and appropriate, coordinate with other 
     appropriate offices on activities within the Department that 
     relate to disease prevention, health promotion, service 
     delivery, research, and public and health care professional 
     education, for issues of particular concern to women 
     throughout their lifespan;
       ``(2) provide expert advice and consultation to the 
     Secretary concerning scientific, legal, ethical, and policy 
     issues relating to women's health;
       ``(3) monitor the Department of Health and Human Services' 
     offices, agencies, and regional activities regarding women's 
     health and identify needs regarding the coordination of 
     activities, including intramural and extramural 
     multidisciplinary activities;
       ``(4) establish a Department of Health and Human Services 
     Coordinating Committee on Women's Health, which shall be 
     chaired by the Deputy Assistant Secretary for Women's Health 
     and composed of senior level representatives from each of the 
     agencies and offices of the Department of Health and Human 
     Services;
       ``(5) establish a National Women's Health Information 
     Center to--
       ``(A) facilitate the exchange of information regarding 
     matters relating to health information, health promotion, 
     preventive health services, research advances, and education 
     in the appropriate use of health care;
       ``(B) facilitate access to such information;
       ``(C) assist in the analysis of issues and problems 
     relating to the matters described in this paragraph; and
       ``(D) provide technical assistance with respect to the 
     exchange of information (including facilitating the 
     development of materials for such technical assistance);
       ``(6) coordinate efforts to promote women's health programs 
     and policies with the private sector; and
       ``(7) through publications and any other means appropriate, 
     provide for the exchange of information between the Office 
     and recipients of grants, contracts, and agreements under 
     subsection (c), and between the Office and health 
     professionals and the general public.
       ``(c) Grants and Contracts Regarding Duties.--
       ``(1) Authority.--In carrying out subsection (b), the 
     Secretary may make grants to, and enter into cooperative 
     agreements, contracts, and interagency agreements with, 
     public and private entities, agencies, and organizations.
       ``(2) Evaluation and dissemination.--The Secretary shall 
     directly or through contracts with public and private 
     entities, agencies, and organizations, provide for 
     evaluations of projects carried out with financial assistance 
     provided under paragraph (1) and for the dissemination of 
     information developed as a result of such projects.
       ``(d) Reports.--Not later than 1 year after the date of 
     enactment of this section, and every second year thereafter, 
     the Secretary shall prepare and submit to the appropriate 
     committees of Congress a report describing the activities 
     carried out under this section during the period for which 
     the report is being prepared.
       ``(e) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.
       (2) Transfer of functions.--There are transferred to the 
     Office on Women's Health (established under section 229 of 
     the Public Health Service Act, as added by this section), all 
     functions exercised by the Office on Women's Health of the 
     Public Health Service prior to the date of enactment of this 
     section, including all personnel and compensation authority, 
     all delegation and assignment authority, and all remaining 
     appropriations. All orders, determinations, rules, 
     regulations, permits, agreements, grants, contracts, 
     certificates, licenses, registrations, privileges, and other 
     administrative actions that--
       (A) have been issued, made, granted, or allowed to become 
     effective by the President, any

[[Page 4314]]

     Federal agency or official thereof, or by a court of 
     competent jurisdiction, in the performance of functions 
     transferred under this paragraph; and
       (B) are in effect at the time this section takes effect, or 
     were final before the date of enactment of this section and 
     are to become effective on or after such date,

     shall continue in effect according to their terms until 
     modified, terminated, superseded, set aside, or revoked in 
     accordance with law by the President, the Secretary, or other 
     authorized official, a court of competent jurisdiction, or by 
     operation of law.
       (b) Centers for Disease Control and Prevention Office of 
     Women's Health.--Part A of title III of the Public Health 
     Service Act (42 U.S.C. 241 et seq.) is amended by adding at 
     the end the following:

     ``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION 
                   OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Director of the Centers for Disease Control and 
     Prevention, an office to be known as the Office of Women's 
     Health (referred to in this section as the `Office'). The 
     Office shall be headed by a director who shall be appointed 
     by the Director of such Centers.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Director of the Centers for Disease 
     Control and Prevention on the current level of the Centers' 
     activity regarding women's health conditions across, where 
     appropriate, age, biological, and sociocultural contexts, in 
     all aspects of the Centers' work, including prevention 
     programs, public and professional education, services, and 
     treatment;
       ``(2) establish short-range and long-range goals and 
     objectives within the Centers for women's health and, as 
     relevant and appropriate, coordinate with other appropriate 
     offices on activities within the Centers that relate to 
     prevention, research, education and training, service 
     delivery, and policy development, for issues of particular 
     concern to women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the Centers;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on the policy of the Centers with regard to 
     women; and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4)).
       ``(c) Definition.--As used in this section, the term 
     `women's health conditions', with respect to women of all 
     age, ethnic, and racial groups, means diseases, disorders, 
     and conditions--
       ``(1) unique to, significantly more serious for, or 
     significantly more prevalent in women; and
       ``(2) for which the factors of medical risk or type of 
     medical intervention are different for women, or for which 
     there is reasonable evidence that indicates that such factors 
     or types may be different for women.
       ``(d) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.
       (c) Office of Women's Health Research.--Section 486(a) of 
     the Public Health Service Act (42 U.S.C. 287d(a)) is amended 
     by inserting ``and who shall report directly to the 
     Director'' before the period at the end thereof.
       (d) Substance Abuse and Mental Health Services 
     Administration.--Section 501(f) of the Public Health Service 
     Act (42 U.S.C. 290aa(f)) is amended--
       (1) in paragraph (1), by inserting ``who shall report 
     directly to the Administrator'' before the period;
       (2) by redesignating paragraph (4) as paragraph (5); and
       (3) by inserting after paragraph (3), the following:
       ``(4) Office.--Nothing in this subsection shall be 
     construed to preclude the Secretary from establishing within 
     the Substance Abuse and Mental Health Administration an 
     Office of Women's Health.''.
       (e) Agency for Healthcare Research and Quality Activities 
     Regarding Women's Health.--Part C of title IX of the Public 
     Health Service Act (42 U.S.C. 299c et seq.) is amended--
       (1) by redesignating sections 925 and 926 as sections 926 
     and 927, respectively; and
       (2) by inserting after section 924 the following:

     ``SEC. 925. ACTIVITIES REGARDING WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Director, an Office of Women's Health and 
     Gender-Based Research (referred to in this section as the 
     `Office'). The Office shall be headed by a director who shall 
     be appointed by the Director of Healthcare and Research 
     Quality.
       ``(b) Purpose.--The official designated under subsection 
     (a) shall--
       ``(1) report to the Director on the current Agency level of 
     activity regarding women's health, across, where appropriate, 
     age, biological, and sociocultural contexts, in all aspects 
     of Agency work, including the development of evidence reports 
     and clinical practice protocols and the conduct of research 
     into patient outcomes, delivery of health care services, 
     quality of care, and access to health care;
       ``(2) establish short-range and long-range goals and 
     objectives within the Agency for research important to 
     women's health and, as relevant and appropriate, coordinate 
     with other appropriate offices on activities within the 
     Agency that relate to health services and medical 
     effectiveness research, for issues of particular concern to 
     women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the Agency;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on Agency policy with regard to women; and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4)).''.
       ``(c) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.
       (f) Health Resources and Services Administration Office of 
     Women's Health.--Title VII of the Social Security Act (42 
     U.S.C. 901 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 713. OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--The Secretary shall establish within 
     the Office of the Administrator of the Health Resources and 
     Services Administration, an office to be known as the Office 
     of Women's Health. The Office shall be headed by a director 
     who shall be appointed by the Administrator.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Administrator on the current 
     Administration level of activity regarding women's health 
     across, where appropriate, age, biological, and sociocultural 
     contexts;
       ``(2) establish short-range and long-range goals and 
     objectives within the Health Resources and Services 
     Administration for women's health and, as relevant and 
     appropriate, coordinate with other appropriate offices on 
     activities within the Administration that relate to health 
     care provider training, health service delivery, research, 
     and demonstration projects, for issues of particular concern 
     to women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the bureaus of the Administration;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on Administration policy with regard to women; 
     and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4) of the Public Health 
     Service Act).
       ``(c) Continued Administration of Existing Programs.--The 
     Director of the Office shall assume the authority for the 
     development, implementation, administration, and evaluation 
     of any projects carried out through the Health Resources and 
     Services Administration relating to women's health on the 
     date of enactment of this section.
       ``(d) Definitions.--For purposes of this section:
       ``(1) Administration.--The term `Administration' means the 
     Health Resources and Services Administration.
       ``(2) Administrator.--The term `Administrator' means the 
     Administrator of the Health Resources and Services 
     Administration.
       ``(3) Office.--The term `Office' means the Office of 
     Women's Health established under this section in the 
     Administration.
       ``(e) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.
       (g) Food and Drug Administration Office of Women's 
     Health.--Chapter X of the Federal Food, Drug, and Cosmetic 
     Act (21 U.S.C. 391 et seq.) is amended by adding at the end 
     the following:

     ``SEC. 1011. OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Commissioner, an office to be known as the 
     Office of Women's Health (referred to in this section as the 
     `Office'). The Office shall be headed by a director who shall 
     be appointed by the Commissioner of Food and Drugs.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Commissioner of Food and Drugs on 
     current Food and Drug Administration (referred to in this 
     section as the `Administration') levels of activity regarding 
     women's participation in clinical trials and the analysis of 
     data by sex in the testing of drugs, medical devices, and 
     biological products across, where appropriate, age, 
     biological, and sociocultural contexts;
       ``(2) establish short-range and long-range goals and 
     objectives within the Administration for issues of particular 
     concern to women's health within the jurisdiction of the 
     Administration, including, where relevant and appropriate, 
     adequate inclusion of women and analysis of data by sex in 
     Administration protocols and policies;
       ``(3) provide information to women and health care 
     providers on those areas in which differences between men and 
     women exist;
       ``(4) consult with pharmaceutical, biologics, and device 
     manufacturers, health professionals with expertise in women's 
     issues, consumer organizations, and women's health 
     professionals on Administration policy with regard to women;
       ``(5) make annual estimates of funds needed to monitor 
     clinical trials and analysis of data by

[[Page 4315]]

     sex in accordance with needs that are identified; and
       ``(6) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4) of the Public Health 
     Service Act).
       ``(c) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.
       (h) No New Regulatory Authority.--Nothing in this section 
     and the amendments made by this section may be construed as 
     establishing regulatory authority or modifying any existing 
     regulatory authority.
       (i) Limitation on Termination.--Notwithstanding any other 
     provision of law, a Federal office of women's health 
     (including the Office of Research on Women's Health of the 
     National Institutes of Health) or Federal appointive position 
     with primary responsibility over women's health issues 
     (including the Associate Administrator for Women's Services 
     under the Substance Abuse and Mental Health Services 
     Administration) that is in existence on the date of enactment 
     of this section shall not be terminated, reorganized, or have 
     any of it's powers or duties transferred unless such 
     termination, reorganization, or transfer is approved by 
     Congress through the adoption of a concurrent resolution of 
     approval.
       (j) Rule of Construction.--Nothing in this section (or the 
     amendments made by this section) shall be construed to limit 
     the authority of the Secretary of Health and Human Services 
     with respect to women's health, or with respect to activities 
     carried out through the Department of Health and Human 
     Services on the date of enactment of this section.

     SEC. 3510. PATIENT NAVIGATOR PROGRAM.

       Section 340A of the Public Health Service Act (42 U.S.C. 
     256a) is amended--
       (1) by striking subsection (d)(3) and inserting the 
     following:
       ``(3) Limitations on grant period.--In carrying out this 
     section, the Secretary shall ensure that the total period of 
     a grant does not exceed 4 years.'';
       (2) in subsection (e), by adding at the end the following:
       ``(3) Minimum core proficiencies.--The Secretary shall not 
     award a grant to an entity under this section unless such 
     entity provides assurances that patient navigators recruited, 
     assigned, trained, or employed using grant funds meet minimum 
     core proficiencies, as defined by the entity that submits the 
     application, that are tailored for the main focus or 
     intervention of the navigator involved.''; and
       (3) in subsection (m)--
       (A) in paragraph (1), by striking ``and $3,500,000 for 
     fiscal year 2010.'' and inserting ``$3,500,000 for fiscal 
     year 2010, and such sums as may be necessary for each of 
     fiscal years 2011 through 2015.''; and
       (B) in paragraph (2), by striking ``2010'' and inserting 
     ``2015''.

     SEC. 3511. AUTHORIZATION OF APPROPRIATIONS.

       Except where otherwise provided in this subtitle (or an 
     amendment made by this subtitle), there is authorized to be 
     appropriated such sums as may be necessary to carry out this 
     subtitle (and such amendments made by this subtitle).

   Subtitle G--Protecting and Improving Guaranteed Medicare Benefits

     SEC. 3601. PROTECTING AND IMPROVING GUARANTEED MEDICARE 
                   BENEFITS.

       (a) Protecting Guaranteed Medicare Benefits.--Nothing in 
     the provisions of, or amendments made by, this Act shall 
     result in a reduction of guaranteed benefits under title 
     XVIII of the Social Security Act.
       (b) Ensuring That Medicare Savings Benefit the Medicare 
     Program and Medicare Beneficiaries.--Savings generated for 
     the Medicare program under title XVIII of the Social Security 
     Act under the provisions of, and amendments made by, this Act 
     shall extend the solvency of the Medicare trust funds, reduce 
     Medicare premiums and other cost-sharing for beneficiaries, 
     and improve or expand guaranteed Medicare benefits and 
     protect access to Medicare providers.

     SEC. 3602. NO CUTS IN GUARANTEED BENEFITS.

       Nothing in this Act shall result in the reduction or 
     elimination of any benefits guaranteed by law to participants 
     in Medicare Advantage plans.

  TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH

  Subtitle A--Modernizing Disease Prevention and Public Health Systems

     SEC. 4001. NATIONAL PREVENTION, HEALTH PROMOTION AND PUBLIC 
                   HEALTH COUNCIL.

       (a) Establishment.--The President shall establish, within 
     the Department of Health and Human Services, a council to be 
     known as the ``National Prevention, Health Promotion and 
     Public Health Council'' (referred to in this section as the 
     ``Council'').
       (b) Chairperson.--The President shall appoint the Surgeon 
     General to serve as the chairperson of the Council.
       (c) Composition.--The Council shall be composed of--
       (1) the Secretary of Health and Human Services;
       (2) the Secretary of Agriculture;
       (3) the Secretary of Education;
       (4) the Chairman of the Federal Trade Commission;
       (5) the Secretary of Transportation;
       (6) the Secretary of Labor;
       (7) the Secretary of Homeland Security;
       (8) the Administrator of the Environmental Protection 
     Agency;
       (9) the Director of the Office of National Drug Control 
     Policy;
       (10) the Director of the Domestic Policy Council;
       (11) the Assistant Secretary for Indian Affairs;
       (12) the Chairman of the Corporation for National and 
     Community Service; and
       (13) the head of any other Federal agency that the 
     chairperson determines is appropriate.
       (d) Purposes and Duties.--The Council shall--
       (1) provide coordination and leadership at the Federal 
     level, and among all Federal departments and agencies, with 
     respect to prevention, wellness and health promotion 
     practices, the public health system, and integrative health 
     care in the United States;
       (2) after obtaining input from relevant stakeholders, 
     develop a national prevention, health promotion, public 
     health, and integrative health care strategy that 
     incorporates the most effective and achievable means of 
     improving the health status of Americans and reducing the 
     incidence of preventable illness and disability in the United 
     States;
       (3) provide recommendations to the President and Congress 
     concerning the most pressing health issues confronting the 
     United States and changes in Federal policy to achieve 
     national wellness, health promotion, and public health goals, 
     including the reduction of tobacco use, sedentary behavior, 
     and poor nutrition;
       (4) consider and propose evidence-based models, policies, 
     and innovative approaches for the promotion of transformative 
     models of prevention, integrative health, and public health 
     on individual and community levels across the United States;
       (5) establish processes for continual public input, 
     including input from State, regional, and local leadership 
     communities and other relevant stakeholders, including Indian 
     tribes and tribal organizations;
       (6) submit the reports required under subsection (g); and
       (7) carry out other activities determined appropriate by 
     the President.
       (e) Meetings.--The Council shall meet at the call of the 
     Chairperson.
       (f) Advisory Group.--
       (1) In general.--The President shall establish an Advisory 
     Group to the Council to be known as the ``Advisory Group on 
     Prevention, Health Promotion, and Integrative and Public 
     Health'' (hereafter referred to in this section as the 
     ``Advisory Group''). The Advisory Group shall be within the 
     Department of Health and Human Services and report to the 
     Surgeon General.
       (2) Composition.--
       (A) In general.--The Advisory Group shall be composed of 
     not more than 25 non-Federal members to be appointed by the 
     President.
       (B) Representation.--In appointing members under 
     subparagraph (A), the President shall ensure that the 
     Advisory Group includes a diverse group of licensed health 
     professionals, including integrative health practitioners who 
     have expertise in--
       (i) worksite health promotion;
       (ii) community services, including community health 
     centers;
       (iii) preventive medicine;
       (iv) health coaching;
       (v) public health education;
       (vi) geriatrics; and
       (vii) rehabilitation medicine.
       (3) Purposes and duties.--The Advisory Group shall develop 
     policy and program recommendations and advise the Council on 
     lifestyle-based chronic disease prevention and management, 
     integrative health care practices, and health promotion.
       (g) National Prevention and Health Promotion Strategy.--Not 
     later than 1 year after the date of enactment of this Act, 
     the Chairperson, in consultation with the Council, shall 
     develop and make public a national prevention, health 
     promotion and public health strategy, and shall review and 
     revise such strategy periodically. Such strategy shall--
       (1) set specific goals and objectives for improving the 
     health of the United States through federally-supported 
     prevention, health promotion, and public health programs, 
     consistent with ongoing goal setting efforts conducted by 
     specific agencies;
       (2) establish specific and measurable actions and timelines 
     to carry out the strategy, and determine accountability for 
     meeting those timelines, within and across Federal 
     departments and agencies; and
       (3) make recommendations to improve Federal efforts 
     relating to prevention, health promotion, public health, and 
     integrative health care practices to ensure Federal efforts 
     are consistent with available standards and evidence.
       (h) Report.--Not later than July 1, 2010, and annually 
     thereafter through January 1, 2015, the Council shall submit 
     to the President and the relevant committees of Congress, a 
     report that--
       (1) describes the activities and efforts on prevention, 
     health promotion, and public health and activities to develop 
     a national strategy conducted by the Council during the 
     period for which the report is prepared;
       (2) describes the national progress in meeting specific 
     prevention, health promotion, and public health goals defined 
     in the strategy and further describes corrective actions 
     recommended by the Council and taken by relevant agencies and 
     organizations to meet these goals;
       (3) contains a list of national priorities on health 
     promotion and disease prevention to address lifestyle 
     behavior modification (smoking

[[Page 4316]]

     cessation, proper nutrition, appropriate exercise, mental 
     health, behavioral health, substance use disorder, and 
     domestic violence screenings) and the prevention measures for 
     the 5 leading disease killers in the United States;
       (4) contains specific science-based initiatives to achieve 
     the measurable goals of Healthy People 2010 regarding 
     nutrition, exercise, and smoking cessation, and targeting the 
     5 leading disease killers in the United States;
       (5) contains specific plans for consolidating Federal 
     health programs and Centers that exist to promote healthy 
     behavior and reduce disease risk (including eliminating 
     programs and offices determined to be ineffective in meeting 
     the priority goals of Healthy People 2010);
       (6) contains specific plans to ensure that all Federal 
     health care programs are fully coordinated with science-based 
     prevention recommendations by the Director of the Centers for 
     Disease Control and Prevention; and
       (7) contains specific plans to ensure that all non-
     Department of Health and Human Services prevention programs 
     are based on the science-based guidelines developed by the 
     Centers for Disease Control and Prevention under paragraph 
     (4).
       (i) Periodic Reviews.--The Secretary and the Comptroller 
     General of the United States shall jointly conduct periodic 
     reviews, not less than every 5 years, and evaluations of 
     every Federal disease prevention and health promotion 
     initiative, program, and agency. Such reviews shall be 
     evaluated based on effectiveness in meeting metrics-based 
     goals with an analysis posted on such agencies' public 
     Internet websites.

     SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND.

       (a) Purpose.--It is the purpose of this section to 
     establish a Prevention and Public Health Fund (referred to in 
     this section as the ``Fund''), to be administered through the 
     Department of Health and Human Services, Office of the 
     Secretary, to provide for expanded and sustained national 
     investment in prevention and public health programs to 
     improve health and help restrain the rate of growth in 
     private and public sector health care costs.
       (b) Funding.--There are hereby authorized to be 
     appropriated, and appropriated, to the Fund, out of any 
     monies in the Treasury not otherwise appropriated--
       (1) for fiscal year 2010, $500,000,000;
       (2) for fiscal year 2011, $750,000,000;
       (3) for fiscal year 2012, $1,000,000,000;
       (4) for fiscal year 2013, $1,250,000,000;
       (5) for fiscal year 2014, $1,500,000,000; and
       (6) for fiscal year 2015, and each fiscal year thereafter, 
     $2,000,000,000.
       (c) Use of Fund.--The Secretary shall transfer amounts in 
     the Fund to accounts within the Department of Health and 
     Human Services to increase funding, over the fiscal year 2008 
     level, for programs authorized by the Public Health Service 
     Act, for prevention, wellness, and public health activities 
     including prevention research and health screenings, such as 
     the Community Transformation grant program, the Education and 
     Outreach Campaign for Preventive Benefits, and immunization 
     programs.
       (d) Transfer Authority.--The Committee on Appropriations of 
     the Senate and the Committee on Appropriations of the House 
     of Representatives may provide for the transfer of funds in 
     the Fund to eligible activities under this section, subject 
     to subsection (c).

     SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES.

       (a) Preventive Services Task Force.--Section 915 of the 
     Public Health Service Act (42 U.S.C. 299b-4) is amended by 
     striking subsection (a) and inserting the following:
       ``(a) Preventive Services Task Force.--
       ``(1) Establishment and purpose.--The Director shall 
     convene an independent Preventive Services Task Force 
     (referred to in this subsection as the `Task Force') to be 
     composed of individuals with appropriate expertise. Such Task 
     Force shall review the scientific evidence related to the 
     effectiveness, appropriateness, and cost-effectiveness of 
     clinical preventive services for the purpose of developing 
     recommendations for the health care community, and updating 
     previous clinical preventive recommendations, to be published 
     in the Guide to Clinical Preventive Services (referred to in 
     this section as the `Guide'), for individuals and 
     organizations delivering clinical services, including primary 
     care professionals, health care systems, professional 
     societies, employers, community organizations, non-profit 
     organizations, Congress and other policy-makers, governmental 
     public health agencies, health care quality organizations, 
     and organizations developing national health objectives. Such 
     recommendations shall consider clinical preventive best 
     practice recommendations from the Agency for Healthcare 
     Research and Quality, the National Institutes of Health, the 
     Centers for Disease Control and Prevention, the Institute of 
     Medicine, specialty medical associations, patient groups, and 
     scientific societies.
       ``(2) Duties.--The duties of the Task Force shall include--
       ``(A) the development of additional topic areas for new 
     recommendations and interventions related to those topic 
     areas, including those related to specific sub-populations 
     and age groups;
       ``(B) at least once during every 5-year period, review 
     interventions and update recommendations related to existing 
     topic areas, including new or improved techniques to assess 
     the health effects of interventions;
       ``(C) improved integration with Federal Government health 
     objectives and related target setting for health improvement;
       ``(D) the enhanced dissemination of recommendations;
       ``(E) the provision of technical assistance to those health 
     care professionals, agencies and organizations that request 
     help in implementing the Guide recommendations; and
       ``(F) the submission of yearly reports to Congress and 
     related agencies identifying gaps in research, such as 
     preventive services that receive an insufficient evidence 
     statement, and recommending priority areas that deserve 
     further examination, including areas related to populations 
     and age groups not adequately addressed by current 
     recommendations.
       ``(3) Role of agency.--The Agency shall provide ongoing 
     administrative, research, and technical support for the 
     operations of the Task Force, including coordinating and 
     supporting the dissemination of the recommendations of the 
     Task Force, ensuring adequate staff resources, and assistance 
     to those organizations requesting it for implementation of 
     the Guide's recommendations.
       ``(4) Coordination with community preventive services task 
     force.--The Task Force shall take appropriate steps to 
     coordinate its work with the Community Preventive Services 
     Task Force and the Advisory Committee on Immunization 
     Practices, including the examination of how each task force's 
     recommendations interact at the nexus of clinic and 
     community.
       ``(5) Operation.--Operation. In carrying out the duties 
     under paragraph (2), the Task Force is not subject to the 
     provisions of Appendix 2 of title 5, United States Code.
       ``(6) Independence.--All members of the Task Force convened 
     under this subsection, and any recommendations made by such 
     members, shall be independent and, to the extent practicable, 
     not subject to political pressure.
       ``(7) Authorization of appropriations.--There are 
     authorized to be appropriated such sums as may be necessary 
     for each fiscal year to carry out the activities of the Task 
     Force.''.
       (b) Community Preventive Services Task Force.--
       (1) In general.--Part P of title III of the Public Health 
     Service Act, as amended by paragraph (2), is amended by 
     adding at the end the following:

     ``SEC. 399U. COMMUNITY PREVENTIVE SERVICES TASK FORCE.

       ``(a) Establishment and Purpose.--The Director of the 
     Centers for Disease Control and Prevention shall convene an 
     independent Community Preventive Services Task Force 
     (referred to in this subsection as the `Task Force') to be 
     composed of individuals with appropriate expertise. Such Task 
     Force shall review the scientific evidence related to the 
     effectiveness, appropriateness, and cost-effectiveness of 
     community preventive interventions for the purpose of 
     developing recommendations, to be published in the Guide to 
     Community Preventive Services (referred to in this section as 
     the `Guide'), for individuals and organizations delivering 
     population-based services, including primary care 
     professionals, health care systems, professional societies, 
     employers, community organizations, non-profit organizations, 
     schools, governmental public health agencies, Indian tribes, 
     tribal organizations and urban Indian organizations, medical 
     groups, Congress and other policy-makers. Community 
     preventive services include any policies, programs, processes 
     or activities designed to affect or otherwise affecting 
     health at the population level.
       ``(b) Duties.--The duties of the Task Force shall include--
       ``(1) the development of additional topic areas for new 
     recommendations and interventions related to those topic 
     areas, including those related to specific populations and 
     age groups, as well as the social, economic and physical 
     environments that can have broad effects on the health and 
     disease of populations and health disparities among sub-
     populations and age groups;
       ``(2) at least once during every 5-year period, review 
     interventions and update recommendations related to existing 
     topic areas, including new or improved techniques to assess 
     the health effects of interventions, including health impact 
     assessment and population health modeling;
       ``(3) improved integration with Federal Government health 
     objectives and related target setting for health improvement;
       ``(4) the enhanced dissemination of recommendations;
       ``(5) the provision of technical assistance to those health 
     care professionals, agencies, and organizations that request 
     help in implementing the Guide recommendations; and
       ``(6) providing yearly reports to Congress and related 
     agencies identifying gaps in research and recommending 
     priority areas that deserve further examination, including 
     areas related to populations and age groups not adequately 
     addressed by current recommendations.
       ``(c) Role of Agency.--The Director shall provide ongoing 
     administrative, research, and technical support for the 
     operations of the Task Force, including coordinating and 
     supporting the dissemination of the recommendations of the 
     Task Force, ensuring adequate staff resources, and assistance 
     to those organizations requesting it for implementation of 
     Guide recommendations.
       ``(d) Coordination With Preventive Services Task Force.--
     The Task Force shall take appropriate steps to coordinate its 
     work with the U.S. Preventive Services Task Force and the 
     Advisory Committee on Immunization Practices, including the 
     examination of how each task force's recommendations interact 
     at the nexus of clinic and community.
       ``(e) Operation.--In carrying out the duties under 
     subsection (b), the Task Force shall not

[[Page 4317]]

     be subject to the provisions of Appendix 2 of title 5, United 
     States Code.
       ``(f) Authorization of Appropriations.--There are 
     authorized to be appropriated such sums as may be necessary 
     for each fiscal year to carry out the activities of the Task 
     Force.''.
       (2) Technical amendments.--
       (A) Section 399R of the Public Health Service Act (as added 
     by section 2 of the ALS Registry Act (Public Law 110-373; 122 
     Stat. 4047)) is redesignated as section 399S.
       (B) Section 399R of such Act (as added by section 3 of the 
     Prenatally and Postnatally Diagnosed Conditions Awareness Act 
     (Public Law 110-374; 122 Stat. 4051)) is redesignated as 
     section 399T.

     SEC. 4004. EDUCATION AND OUTREACH CAMPAIGN REGARDING 
                   PREVENTIVE BENEFITS.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     provide for the planning and implementation of a national 
     public-private partnership for a prevention and health 
     promotion outreach and education campaign to raise public 
     awareness of health improvement across the life span. Such 
     campaign shall include the dissemination of information 
     that--
       (1) describes the importance of utilizing preventive 
     services to promote wellness, reduce health disparities, and 
     mitigate chronic disease;
       (2) promotes the use of preventive services recommended by 
     the United States Preventive Services Task Force and the 
     Community Preventive Services Task Force;
       (3) encourages healthy behaviors linked to the prevention 
     of chronic diseases;
       (4) explains the preventive services covered under health 
     plans offered through a Gateway;
       (5) describes additional preventive care supported by the 
     Centers for Disease Control and Prevention, the Health 
     Resources and Services Administration, the Substance Abuse 
     and Mental Health Services Administration, the Advisory 
     Committee on Immunization Practices, and other appropriate 
     agencies; and
       (6) includes general health promotion information.
       (b) Consultation.--In coordinating the campaign under 
     subsection (a), the Secretary shall consult with the 
     Institute of Medicine to provide ongoing advice on evidence-
     based scientific information for policy, program development, 
     and evaluation.
       (c) Media Campaign.--
       (1) In general.--Not later than 1 year after the date of 
     enactment of this Act, the Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish and implement a national science-based media 
     campaign on health promotion and disease prevention.
       (2) Requirement of campaign.--The campaign implemented 
     under paragraph (1)--
       (A) shall be designed to address proper nutrition, regular 
     exercise, smoking cessation, obesity reduction, the 5 leading 
     disease killers in the United States, and secondary 
     prevention through disease screening promotion;
       (B) shall be carried out through competitively bid 
     contracts awarded to entities providing for the professional 
     production and design of such campaign;
       (C) may include the use of television, radio, Internet, and 
     other commercial marketing venues and may be targeted to 
     specific age groups based on peer-reviewed social research;
       (D) shall not be duplicative of any other Federal efforts 
     relating to health promotion and disease prevention; and
       (E) may include the use of humor and nationally recognized 
     positive role models.
       (3) Evaluation.--The Secretary shall ensure that the 
     campaign implemented under paragraph (1) is subject to an 
     independent evaluation every 2 years and shall report every 2 
     years to Congress on the effectiveness of such campaigns 
     towards meeting science-based metrics.
       (d) Website.--The Secretary, in consultation with private-
     sector experts, shall maintain or enter into a contract to 
     maintain an Internet website to provide science-based 
     information on guidelines for nutrition, regular exercise, 
     obesity reduction, smoking cessation, and specific chronic 
     disease prevention. Such website shall be designed to provide 
     information to health care providers and consumers.
       (e) Dissemination of Information Through Providers.--The 
     Secretary, acting through the Centers for Disease Control and 
     Prevention, shall develop and implement a plan for the 
     dissemination of health promotion and disease prevention 
     information consistent with national priorities, to health 
     care providers who participate in Federal programs, including 
     programs administered by the Indian Health Service, the 
     Department of Veterans Affairs, the Department of Defense, 
     and the Health Resources and Services Administration, and 
     Medicare and Medicaid.
       (f) Personalized Prevention Plans.--
       (1) Contract.--The Secretary, acting through the Director 
     of the Centers for Disease Control and Prevention, shall 
     enter into a contract with a qualified entity for the 
     development and operation of a Federal Internet website 
     personalized prevention plan tool.
       (2) Use.--The website developed under paragraph (1) shall 
     be designed to be used as a source of the most up-to-date 
     scientific evidence relating to disease prevention for use by 
     individuals. Such website shall contain a component that 
     enables an individual to determine their disease risk (based 
     on personal health and family history, BMI, and other 
     relevant information) relating to the 5 leading diseases in 
     the United States, and obtain personalized suggestions for 
     preventing such diseases.
       (g) Internet Portal.--The Secretary shall establish an 
     Internet portal for accessing risk-assessment tools developed 
     and maintained by private and academic entities.
       (h) Priority Funding.--Funding for the activities 
     authorized under this section shall take priority over 
     funding provided through the Centers for Disease Control and 
     Prevention for grants to States and other entities for 
     similar purposes and goals as provided for in this section. 
     Not to exceed $500,000,000 shall be expended on the campaigns 
     and activities required under this section.
       (i) Public Awareness of Preventive and Obesity-Related 
     Services.--
       (1) Information to states.--The Secretary of Health and 
     Human Services shall provide guidance and relevant 
     information to States and health care providers regarding 
     preventive and obesity-related services that are available to 
     Medicaid enrollees, including obesity screening and 
     counseling for children and adults.
       (2) Information to enrollees.--Each State shall design a 
     public awareness campaign to educate Medicaid enrollees 
     regarding availability and coverage of such services, with 
     the goal of reducing incidences of obesity.
       (3) Report.--Not later than January 1, 2011, and every 3 
     years thereafter through January 1, 2017, the Secretary of 
     Health and Human Services shall report to Congress on the 
     status and effectiveness of efforts under paragraphs (1) and 
     (2), including summaries of the States' efforts to increase 
     awareness of coverage of obesity-related services.
       (j) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     Subtitle B--Increasing Access to Clinical Preventive Services

     SEC. 4101. SCHOOL-BASED HEALTH CENTERS.

       (a) Grants for the Establishment of School-Based Health 
     Centers.--
       (1) Program.--The Secretary of Health and Human Services 
     (in this subsection referred to as the ``Secretary'') shall 
     establish a program to award grants to eligible entities to 
     support the operation of school-based health centers.
       (2) Eligibility.--To be eligible for a grant under this 
     subsection, an entity shall--
       (A) be a school-based health center or a sponsoring 
     facility of a school-based health center; and
       (B) submit an application at such time, in such manner, and 
     containing such information as the Secretary may require, 
     including at a minimum an assurance that funds awarded under 
     the grant shall not be used to provide any service that is 
     not authorized or allowed by Federal, State, or local law.
       (3) Preference.--In awarding grants under this section, the 
     Secretary shall give preference to awarding grants for 
     school-based health centers that serve a large population of 
     children eligible for medical assistance under the State 
     Medicaid plan under title XIX of the Social Security Act or 
     under a waiver of such plan or children eligible for child 
     health assistance under the State child health plan under 
     title XXI of that Act (42 U.S.C. 1397aa et seq.).
       (4) Limitation on use of funds.--An eligible entity shall 
     use funds provided under a grant awarded under this 
     subsection only for expenditures for facilities (including 
     the acquisition or improvement of land, or the acquisition, 
     construction, expansion, replacement, or other improvement of 
     any building or other facility), equipment, or similar 
     expenditures, as specified by the Secretary. No funds 
     provided under a grant awarded under this section shall be 
     used for expenditures for personnel or to provide health 
     services.
       (5) Appropriations.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated for each of 
     fiscal years 2010 through 2013, $50,000,000 for the purpose 
     of carrying out this subsection. Funds appropriated under 
     this paragraph shall remain available until expended.
       (6) Definitions.--In this subsection, the terms ``school-
     based health center'' and ``sponsoring facility'' have the 
     meanings given those terms in section 2110(c)(9) of the 
     Social Security Act (42 U.S.C. 1397jj(c)(9)).
       (b) Grants for the Operation of School-Based Health 
     Centers.--Part Q of title III of the Public Health Service 
     Act (42 U.S.C. 280h et seq.) is amended by adding at the end 
     the following:

     ``SEC. 399Z-1. SCHOOL-BASED HEALTH CENTERS.

       ``(a) Definitions; Establishment of Criteria.--In this 
     section:
       ``(1) Comprehensive primary health services.--The term 
     `comprehensive primary health services' means the core 
     services offered by school-based health centers, which shall 
     include the following:
       ``(A) Physical.--Comprehensive health assessments, 
     diagnosis, and treatment of minor, acute, and chronic medical 
     conditions, and referrals to, and follow-up for, specialty 
     care and oral health services.
       ``(B) Mental health.--Mental health and substance use 
     disorder assessments, crisis intervention, counseling, 
     treatment, and referral to a continuum of services including 
     emergency psychiatric care, community support programs, 
     inpatient care, and outpatient programs.
       ``(2) Medically underserved children and adolescents.--

[[Page 4318]]

       ``(A) In general.--The term `medically underserved children 
     and adolescents' means a population of children and 
     adolescents who are residents of an area designated as a 
     medically underserved area or a health professional shortage 
     area by the Secretary.
       ``(B) Criteria.--The Secretary shall prescribe criteria for 
     determining the specific shortages of personal health 
     services for medically underserved children and adolescents 
     under subparagraph (A) that shall--
       ``(i) take into account any comments received by the 
     Secretary from the chief executive officer of a State and 
     local officials in a State; and
       ``(ii) include factors indicative of the health status of 
     such children and adolescents of an area, including the 
     ability of the residents of such area to pay for health 
     services, the accessibility of such services, the 
     availability of health professionals to such children and 
     adolescents, and other factors as determined appropriate by 
     the Secretary.
       ``(3) School-based health center.--The term `school-based 
     health center' means a health clinic that--
       ``(A) meets the definition of a school-based health center 
     under section 2110(c)(9)(A) of the Social Security Act and is 
     administered by a sponsoring facility (as defined in section 
     2110(c)(9)(B) of the Social Security Act);
       ``(B) provides, at a minimum, comprehensive primary health 
     services during school hours to children and adolescents by 
     health professionals in accordance with established 
     standards, community practice, reporting laws, and other 
     State laws, including parental consent and notification laws 
     that are not inconsistent with Federal law; and
       ``(C) does not perform abortion services.
       ``(b) Authority To Award Grants.--The Secretary shall award 
     grants for the costs of the operation of school-based health 
     centers (referred to in this section as `SBHCs') that meet 
     the requirements of this section.
       ``(c) Applications.--To be eligible to receive a grant 
     under this section, an entity shall--
       ``(1) be an SBHC (as defined in subsection (a)(3)); and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing--
       ``(A) evidence that the applicant meets all criteria 
     necessary to be designated an SBHC;
       ``(B) evidence of local need for the services to be 
     provided by the SBHC;
       ``(C) an assurance that--
       ``(i) SBHC services will be provided to those children and 
     adolescents for whom parental or guardian consent has been 
     obtained in cooperation with Federal, State, and local laws 
     governing health care service provision to children and 
     adolescents;
       ``(ii) the SBHC has made and will continue to make every 
     reasonable effort to establish and maintain collaborative 
     relationships with other health care providers in the 
     catchment area of the SBHC;
       ``(iii) the SBHC will provide on-site access during the 
     academic day when school is in session and 24-hour coverage 
     through an on-call system and through its backup health 
     providers to ensure access to services on a year-round basis 
     when the school or the SBHC is closed;
       ``(iv) the SBHC will be integrated into the school 
     environment and will coordinate health services with school 
     personnel, such as administrators, teachers, nurses, 
     counselors, and support personnel, as well as with other 
     community providers co-located at the school;
       ``(v) the SBHC sponsoring facility assumes all 
     responsibility for the SBHC administration, operations, and 
     oversight; and
       ``(vi) the SBHC will comply with Federal, State, and local 
     laws concerning patient privacy and student records, 
     including regulations promulgated under the Health Insurance 
     Portability and Accountability Act of 1996 and section 444 of 
     the General Education Provisions Act; and
       ``(D) such other information as the Secretary may require.
       ``(d) Preferences and Consideration.--In reviewing 
     applications:
       ``(1) The Secretary may give preference to applicants who 
     demonstrate an ability to serve the following:
       ``(A) Communities that have evidenced barriers to primary 
     health care and mental health and substance use disorder 
     prevention services for children and adolescents.
       ``(B) Communities with high per capita numbers of children 
     and adolescents who are uninsured, underinsured, or enrolled 
     in public health insurance programs.
       ``(C) Populations of children and adolescents that have 
     historically demonstrated difficulty in accessing health and 
     mental health and substance use disorder prevention services.
       ``(2) The Secretary may give consideration to whether an 
     applicant has received a grant under subsection (a) of 
     section 4101 of the Patient Protection and Affordable Care 
     Act.
       ``(e) Waiver of Requirements.--The Secretary may--
       ``(1) under appropriate circumstances, waive the 
     application of all or part of the requirements of this 
     subsection with respect to an SBHC for not to exceed 2 years; 
     and
       ``(2) upon a showing of good cause, waive the requirement 
     that the SBHC provide all required comprehensive primary 
     health services for a designated period of time to be 
     determined by the Secretary.
       ``(f) Use of Funds.--
       ``(1) Funds.--Funds awarded under a grant under this 
     section--
       ``(A) may be used for--
       ``(i) acquiring and leasing equipment (including the costs 
     of amortizing the principle of, and paying interest on, loans 
     for such equipment);
       ``(ii) providing training related to the provision of 
     required comprehensive primary health services and additional 
     health services;
       ``(iii) the management and operation of health center 
     programs;
       ``(iv) the payment of salaries for physicians, nurses, and 
     other personnel of the SBHC; and
       ``(B) may not be used to provide abortions.
       ``(2) Construction.--The Secretary may award grants which 
     may be used to pay the costs associated with expanding and 
     modernizing existing buildings for use as an SBHC, including 
     the purchase of trailers or manufactured buildings to install 
     on the school property.
       ``(3) Limitations.--
       ``(A) In general.--Any provider of services that is 
     determined by a State to be in violation of a State law 
     described in subsection (a)(3)(B) with respect to activities 
     carried out at a SBHC shall not be eligible to receive 
     additional funding under this section.
       ``(B) No overlapping grant period.--No entity that has 
     received funding under section 330 for a grant period shall 
     be eligible for a grant under this section for with respect 
     to the same grant period.
       ``(g) Matching Requirement.--
       ``(1) In general.--Each eligible entity that receives a 
     grant under this section shall provide, from non-Federal 
     sources, an amount equal to 20 percent of the amount of the 
     grant (which may be provided in cash or in-kind) to carry out 
     the activities supported by the grant.
       ``(2) Waiver.--The Secretary may waive all or part of the 
     matching requirement described in paragraph (1) for any 
     fiscal year for the SBHC if the Secretary determines that 
     applying the matching requirement to the SBHC would result in 
     serious hardship or an inability to carry out the purposes of 
     this section.
       ``(h) Supplement, Not Supplant.--Grant funds provided under 
     this section shall be used to supplement, not supplant, other 
     Federal or State funds.
       ``(i) Evaluation.--The Secretary shall develop and 
     implement a plan for evaluating SBHCs and monitoring quality 
     performance under the awards made under this section.
       ``(j) Age Appropriate Services.--An eligible entity 
     receiving funds under this section shall only provide age 
     appropriate services through a SBHC funded under this section 
     to an individual.
       ``(k) Parental Consent.--An eligible entity receiving funds 
     under this section shall not provide services through a SBHC 
     funded under this section to an individual without the 
     consent of the parent or guardian of such individual if such 
     individual is considered a minor under applicable State law.
       ``(l) Authorization of Appropriations.--For purposes of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of the 
     fiscal years 2010 through 2014.''.

     SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES.

       (a) In General.--Title III of the Public Health Service Act 
     (42 U.S.C. 241 et seq.), as amended by section 3025, is 
     amended by adding at the end the following:

            ``PART T--ORAL HEALTHCARE PREVENTION ACTIVITIES

     ``SEC. 399LL. ORAL HEALTHCARE PREVENTION EDUCATION CAMPAIGN.

       ``(a) Establishment.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention 
     and in consultation with professional oral health 
     organizations, shall, subject to the availability of 
     appropriations, establish a 5-year national, public education 
     campaign (referred to in this section as the `campaign') that 
     is focused on oral healthcare prevention and education, 
     including prevention of oral disease such as early childhood 
     and other caries, periodontal disease, and oral cancer.
       ``(b) Requirements.--In establishing the campaign, the 
     Secretary shall--
       ``(1) ensure that activities are targeted towards specific 
     populations such as children, pregnant women, parents, the 
     elderly, individuals with disabilities, and ethnic and racial 
     minority populations, including Indians, Alaska Natives and 
     Native Hawaiians (as defined in section 4(c) of the Indian 
     Health Care Improvement Act) in a culturally and 
     linguistically appropriate manner; and
       ``(2) utilize science-based strategies to convey oral 
     health prevention messages that include, but are not limited 
     to, community water fluoridation and dental sealants.
       ``(c) Planning and Implementation.--Not later than 2 years 
     after the date of enactment of this section, the Secretary 
     shall begin implementing the 5-year campaign. During the 2-
     year period referred to in the previous sentence, the 
     Secretary shall conduct planning activities with respect to 
     the campaign.

     ``SEC. 399LL-1. RESEARCH-BASED DENTAL CARIES DISEASE 
                   MANAGEMENT.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall award demonstration grants to eligible entities to 
     demonstrate the effectiveness of research-based dental caries 
     disease management activities.
       ``(b) Eligibility.--To be eligible for a grant under this 
     section, an entity shall--
       ``(1) be a community-based provider of dental services (as 
     defined by the Secretary), including a Federally-qualified 
     health center, a clinic of a hospital owned or operated by a 
     State (or by an instrumentality or a unit of government 
     within

[[Page 4319]]

     a State), a State or local department of health, a dental 
     program of the Indian Health Service, an Indian tribe or 
     tribal organization, or an urban Indian organization (as such 
     terms are defined in section 4 of the Indian Health Care 
     Improvement Act), a health system provider, a private 
     provider of dental services, medical, dental, public health, 
     nursing, nutrition educational institutions, or national 
     organizations involved in improving children's oral health; 
     and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(c) Use of Funds.--A grantee shall use amounts received 
     under a grant under this section to demonstrate the 
     effectiveness of research-based dental caries disease 
     management activities.
       ``(d) Use of Information.--The Secretary shall utilize 
     information generated from grantees under this section in 
     planning and implementing the public education campaign under 
     section 399LL.

     ``SEC. 399LL-2. AUTHORIZATION OF APPROPRIATIONS.

       ``There is authorized to be appropriated to carry out this 
     part, such sums as may be necessary.''.
       (b) School-Based Sealant Programs.--Section 317M(c)(1) of 
     the Public Health Service Act (42 U.S.C. 247b-14(c)(1)) is 
     amended by striking ``may award grants to States and Indian 
     tribes'' and inserting ``shall award a grant to each of the 
     50 States and territories and to Indians, Indian tribes, 
     tribal organizations and urban Indian organizations (as such 
     terms are defined in section 4 of the Indian Health Care 
     Improvement Act)''.
       (c) Oral Health Infrastructure.--Section 317M of the Public 
     Health Service Act (42 U.S.C. 247b-14) is amended--
       (1) by redesignating subsections (d) and (e) as subsections 
     (e) and (f), respectively; and
       (2) by inserting after subsection (c), the following:
       ``(d) Oral Health Infrastructure.--
       ``(1) Cooperative agreements.--The Secretary, acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall enter into cooperative agreements with 
     State, territorial, and Indian tribes or tribal organizations 
     (as those terms are defined in section 4 of the Indian Health 
     Care Improvement Act) to establish oral health leadership and 
     program guidance, oral health data collection and 
     interpretation, (including determinants of poor oral health 
     among vulnerable populations), a multi-dimensional delivery 
     system for oral health, and to implement science-based 
     programs (including dental sealants and community water 
     fluoridation) to improve oral health.
       ``(2) Authorization of appropriations.--There is authorized 
     to be appropriated such sums as necessary to carry out this 
     subsection for fiscal years 2010 through 2014.''.
       (d) Updating National Oral Healthcare Surveillance 
     Activities.--
       (1) PRAMS.--
       (A) In general.--The Secretary of Health and Human Services 
     (referred to in this subsection as the ``Secretary'') shall 
     carry out activities to update and improve the Pregnancy Risk 
     Assessment Monitoring System (referred to in this section as 
     ``PRAMS'') as it relates to oral healthcare.
       (B) State reports and mandatory measurements.--
       (i) In general.--Not later than 5 years after the date of 
     enactment of this Act, and every 5 years thereafter, a State 
     shall submit to the Secretary a report concerning activities 
     conducted within the State under PRAMS.
       (ii) Measurements.--The oral healthcare measurements 
     developed by the Secretary for use under PRAMS shall be 
     mandatory with respect to States for purposes of the State 
     reports under clause (i).
       (C) Funding.--There is authorized to be appropriated to 
     carry out this paragraph, such sums as may be necessary.
       (2) National health and nutrition examination survey.--The 
     Secretary shall develop oral healthcare components that shall 
     include tooth-level surveillance for inclusion in the 
     National Health and Nutrition Examination Survey. Such 
     components shall be updated by the Secretary at least every 6 
     years. For purposes of this paragraph, the term ``tooth-level 
     surveillance'' means a clinical examination where an examiner 
     looks at each dental surface, on each tooth in the mouth and 
     as expanded by the Division of Oral Health of the Centers for 
     Disease Control and Prevention.
       (3) Medical expenditures panel survey.--The Secretary shall 
     ensure that the Medical Expenditures Panel Survey by the 
     Agency for Healthcare Research and Quality includes the 
     verification of dental utilization, expenditure, and coverage 
     findings through conduct of a look-back analysis.
       (4) National oral health surveillance system.--
       (A) Appropriations.--There is authorized to be 
     appropriated, such sums as may be necessary for each of 
     fiscal years 2010 through 2014 to increase the participation 
     of States in the National Oral Health Surveillance System 
     from 16 States to all 50 States, territories, and District of 
     Columbia.
       (B) Requirements.--The Secretary shall ensure that the 
     National Oral Health Surveillance System include the 
     measurement of early childhood caries.

     SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT 
                   PROVIDING A PERSONALIZED PREVENTION PLAN.

       (a) Coverage of Personalized Prevention Plan Services.--
       (1) In general.--Section 1861(s)(2) of the Social Security 
     Act (42 U.S.C. 1395x(s)(2)) is amended--
       (A) in subparagraph (DD), by striking ``and'' at the end;
       (B) in subparagraph (EE), by adding ``and'' at the end; and
       (C) by adding at the end the following new subparagraph:
       ``(FF) personalized prevention plan services (as defined in 
     subsection (hhh));''.
       (2) Conforming amendments.--Clauses (i) and (ii) of section 
     1861(s)(2)(K) of the Social Security Act (42 U.S.C. 
     1395x(s)(2)(K)) are each amended by striking ``subsection 
     (ww)(1)'' and inserting ``subsections (ww)(1) and (hhh)''.
       (b) Personalized Prevention Plan Services Defined.--Section 
     1861 of the Social Security Act (42 U.S.C. 1395x) is amended 
     by adding at the end the following new subsection:

                        ``Annual Wellness Visit

       ``(hhh)(1) The term `personalized prevention plan services' 
     means the creation of a plan for an individual--
       ``(A) that includes a health risk assessment (that meets 
     the guidelines established by the Secretary under paragraph 
     (4)(A)) of the individual that is completed prior to or as 
     part of the same visit with a health professional described 
     in paragraph (3); and
       ``(B) that--
       ``(i) takes into account the results of the health risk 
     assessment; and
       ``(ii) may contain the elements described in paragraph (2).
       ``(2) Subject to paragraph (4)(H), the elements described 
     in this paragraph are the following:
       ``(A) The establishment of, or an update to, the 
     individual's medical and family history.
       ``(B) A list of current providers and suppliers that are 
     regularly involved in providing medical care to the 
     individual (including a list of all prescribed medications).
       ``(C) A measurement of height, weight, body mass index (or 
     waist circumference, if appropriate), blood pressure, and 
     other routine measurements.
       ``(D) Detection of any cognitive impairment.
       ``(E) The establishment of, or an update to, the following:
       ``(i) A screening schedule for the next 5 to 10 years, as 
     appropriate, based on recommendations of the United States 
     Preventive Services Task Force and the Advisory Committee on 
     Immunization Practices, and the individual's health status, 
     screening history, and age-appropriate preventive services 
     covered under this title.
       ``(ii) A list of risk factors and conditions for which 
     primary, secondary, or tertiary prevention interventions are 
     recommended or are underway, including any mental health 
     conditions or any such risk factors or conditions that have 
     been identified through an initial preventive physical 
     examination (as described under subsection (ww)(1)), and a 
     list of treatment options and their associated risks and 
     benefits.
       ``(F) The furnishing of personalized health advice and a 
     referral, as appropriate, to health education or preventive 
     counseling services or programs aimed at reducing identified 
     risk factors and improving self-management, or community-
     based lifestyle interventions to reduce health risks and 
     promote self-management and wellness, including weight loss, 
     physical activity, smoking cessation, fall prevention, and 
     nutrition.
       ``(G) Any other element determined appropriate by the 
     Secretary.
       ``(3) A health professional described in this paragraph 
     is--
       ``(A) a physician;
       ``(B) a practitioner described in clause (i) of section 
     1842(b)(18)(C); or
       ``(C) a medical professional (including a health educator, 
     registered dietitian, or nutrition professional) or a team of 
     medical professionals, as determined appropriate by the 
     Secretary, under the supervision of a physician.
       ``(4)(A) For purposes of paragraph (1)(A), the Secretary, 
     not later than 1 year after the date of enactment of this 
     subsection, shall establish publicly available guidelines for 
     health risk assessments. Such guidelines shall be developed 
     in consultation with relevant groups and entities and shall 
     provide that a health risk assessment--
       ``(i) identify chronic diseases, injury risks, modifiable 
     risk factors, and urgent health needs of the individual; and
       ``(ii) may be furnished--
       ``(I) through an interactive telephonic or web-based 
     program that meets the standards established under 
     subparagraph (B);
       ``(II) during an encounter with a health care professional;
       ``(III) through community-based prevention programs; or
       ``(IV) through any other means the Secretary determines 
     appropriate to maximize accessibility and ease of use by 
     beneficiaries, while ensuring the privacy of such 
     beneficiaries.
       ``(B) Not later than 1 year after the date of enactment of 
     this subsection, the Secretary shall establish standards for 
     interactive telephonic or web-based programs used to furnish 
     health risk assessments under subparagraph (A)(ii)(I). The 
     Secretary may utilize any health risk assessment developed 
     under section 4004(f) of the Patient Protection and 
     Affordable Care Act as part of the requirement to develop a 
     personalized prevention plan to comply with this 
     subparagraph.
       ``(C)(i) Not later than 18 months after the date of 
     enactment of this subsection, the Secretary shall develop and 
     make available to the public a

[[Page 4320]]

     health risk assessment model. Such model shall meet the 
     guidelines under subparagraph (A) and may be used to meet the 
     requirement under paragraph (1)(A).
       ``(ii) Any health risk assessment that meets the guidelines 
     under subparagraph (A) and is approved by the Secretary may 
     be used to meet the requirement under paragraph (1)(A).
       ``(D) The Secretary may coordinate with community-based 
     entities (including State Health Insurance Programs, Area 
     Agencies on Aging, Aging and Disability Resource Centers, and 
     the Administration on Aging) to--
       ``(i) ensure that health risk assessments are accessible to 
     beneficiaries; and
       ``(ii) provide appropriate support for the completion of 
     health risk assessments by beneficiaries.
       ``(E) The Secretary shall establish procedures to make 
     beneficiaries and providers aware of the requirement that a 
     beneficiary complete a health risk assessment prior to or at 
     the same time as receiving personalized prevention plan 
     services.
       ``(F) To the extent practicable, the Secretary shall 
     encourage the use of, integration with, and coordination of 
     health information technology (including use of technology 
     that is compatible with electronic medical records and 
     personal health records) and may experiment with the use of 
     personalized technology to aid in the development of self-
     management skills and management of and adherence to provider 
     recommendations in order to improve the health status of 
     beneficiaries.
       ``(G)(i) A beneficiary shall only be eligible to receive an 
     initial preventive physical examination (as defined under 
     subsection (ww)(1)) at any time during the 12-month period 
     after the date that the beneficiary's coverage begins under 
     part B and shall be eligible to receive personalized 
     prevention plan services under this subsection provided that 
     the beneficiary has not received such services within the 
     preceding 12-month period.
       ``(ii) The Secretary shall establish procedures to make 
     beneficiaries aware of the option to select an initial 
     preventive physical examination or personalized prevention 
     plan services during the period of 12 months after the date 
     that a beneficiary's coverage begins under part B, which 
     shall include information regarding any relevant differences 
     between such services.
       ``(H) The Secretary shall issue guidance that--
       ``(i) identifies elements under paragraph (2) that are 
     required to be provided to a beneficiary as part of their 
     first visit for personalized prevention plan services; and
       ``(ii) establishes a yearly schedule for appropriate 
     provision of such elements thereafter.''.
       (c) Payment and Elimination of Cost-Sharing.--
       (1) Payment and elimination of coinsurance.--Section 
     1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) 
     is amended--
       (A) in subparagraph (N), by inserting ``other than 
     personalized prevention plan services (as defined in section 
     1861(hhh)(1))'' after ``(as defined in section 1848(j)(3))'';
       (B) by striking ``and'' before ``(W)''; and
       (C) by inserting before the semicolon at the end the 
     following: ``, and (X) with respect to personalized 
     prevention plan services (as defined in section 
     1861(hhh)(1)), the amount paid shall be 100 percent of the 
     lesser of the actual charge for the services or the amount 
     determined under the payment basis determined under section 
     1848''.
       (2) Payment under physician fee schedule.--Section 
     1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-
     4(j)(3)) is amended by inserting ``(2)(FF) (including 
     administration of the health risk assessment) ,'' after 
     ``(2)(EE),''.
       (3) Elimination of coinsurance in outpatient hospital 
     settings.--
       (A) Exclusion from opd fee schedule.--Section 
     1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
     1395l(t)(1)(B)(iv)) is amended by striking ``and diagnostic 
     mammography'' and inserting ``, diagnostic mammography, or 
     personalized prevention plan services (as defined in section 
     1861(hhh)(1))''.
       (B) Conforming amendments.--Section 1833(a)(2) of the 
     Social Security Act (42 U.S.C. 1395l(a)(2)) is amended--
       (i) in subparagraph (F), by striking ``and'' at the end;
       (ii) in subparagraph (G)(ii), by striking the comma at the 
     end and inserting ``; and''; and
       (iii) by inserting after subparagraph (G)(ii) the following 
     new subparagraph:
       ``(H) with respect to personalized prevention plan services 
     (as defined in section 1861(hhh)(1)) furnished by an 
     outpatient department of a hospital, the amount determined 
     under paragraph (1)(X),''.
       (4) Waiver of application of deductible.--The first 
     sentence of section 1833(b) of the Social Security Act (42 
     U.S.C. 1395l(b)) is amended--
       (A) by striking ``and'' before ``(9)''; and
       (B) by inserting before the period the following: ``, and 
     (10) such deductible shall not apply with respect to 
     personalized prevention plan services (as defined in section 
     1861(hhh)(1))''.
       (d) Frequency Limitation.--Section 1862(a) of the Social 
     Security Act (42 U.S.C. 1395y(a)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (N), by striking ``and'' at the end;
       (B) in subparagraph (O), by striking the semicolon at the 
     end and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(P) in the case of personalized prevention plan services 
     (as defined in section 1861(hhh)(1)), which are performed 
     more frequently than is covered under such section;''; and
       (2) in paragraph (7), by striking ``or (K)'' and inserting 
     ``(K), or (P)''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2011.

     SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN 
                   MEDICARE.

       (a) Definition of Preventive Services.--Section 1861(ddd) 
     of the Social Security Act (42 U.S.C. 1395x(ddd)) is 
     amended--
       (1) in the heading, by inserting ``; Preventive Services'' 
     after ``Services'';
       (2) in paragraph (1), by striking ``not otherwise described 
     in this title'' and inserting ``not described in subparagraph 
     (A) or (C) of paragraph (3)''; and
       (3) by adding at the end the following new paragraph:
       ``(3) The term `preventive services' means the following:
       ``(A) The screening and preventive services described in 
     subsection (ww)(2) (other than the service described in 
     subparagraph (M) of such subsection).
       ``(B) An initial preventive physical examination (as 
     defined in subsection (ww)).
       ``(C) Personalized prevention plan services (as defined in 
     subsection (hhh)(1)).''.
       (b) Coinsurance.--
       (1) General application.--
       (A) In general.--Section 1833(a)(1) of the Social Security 
     Act (42 U.S.C. 1395l(a)(1)), as amended by section 
     4103(c)(1), is amended--
       (i) in subparagraph (T), by inserting ``(or 100 percent if 
     such services are recommended with a grade of A or B by the 
     United States Preventive Services Task Force for any 
     indication or population and are appropriate for the 
     individual)'' after ``80 percent'';
       (ii) in subparagraph (W)--

       (I) in clause (i), by inserting ``(if such subparagraph 
     were applied, by substituting `100 percent' for `80 
     percent')'' after ``subparagraph (D)''; and
       (II) in clause (ii), by striking ``80 percent'' and 
     inserting ``100 percent'';

       (iii) by striking ``and'' before ``(X)''; and
       (iv) by inserting before the semicolon at the end the 
     following: ``, and (Y) with respect to preventive services 
     described in subparagraphs (A) and (B) of section 
     1861(ddd)(3) that are appropriate for the individual and, in 
     the case of such services described in subparagraph (A), are 
     recommended with a grade of A or B by the United States 
     Preventive Services Task Force for any indication or 
     population, the amount paid shall be 100 percent of the 
     lesser of the actual charge for the services or the amount 
     determined under the fee schedule that applies to such 
     services under this part''.
       (2) Elimination of coinsurance in outpatient hospital 
     settings.--
       (A) Exclusion from opd fee schedule.--Section 
     1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
     1395l(t)(1)(B)(iv)), as amended by section 4103(c)(3)(A), is 
     amended--
       (i) by striking ``or'' before ``personalized prevention 
     plan services''; and
       (ii) by inserting before the period the following: ``, or 
     preventive services described in subparagraphs (A) and (B) of 
     section 1861(ddd)(3) that are appropriate for the individual 
     and, in the case of such services described in subparagraph 
     (A), are recommended with a grade of A or B by the United 
     States Preventive Services Task Force for any indication or 
     population''.
       (B) Conforming amendments.--Section 1833(a)(2) of the 
     Social Security Act (42 U.S.C. 1395l(a)(2)), as amended by 
     section 4103(c)(3)(B), is amended--
       (i) in subparagraph (G)(ii), by striking ``and'' after the 
     semicolon at the end;
       (ii) in subparagraph (H), by striking the comma at the end 
     and inserting ``; and''; and
       (iii) by inserting after subparagraph (H) the following new 
     subparagraph:
       ``(I) with respect to preventive services described in 
     subparagraphs (A) and (B) of section 1861(ddd)(3) that are 
     appropriate for the individual and are furnished by an 
     outpatient department of a hospital and, in the case of such 
     services described in subparagraph (A), are recommended with 
     a grade of A or B by the United States Preventive Services 
     Task Force for any indication or population, the amount 
     determined under paragraph (1)(W) or (1)(Y),''.
       (c) Waiver of Application of Deductible for Preventive 
     Services and Colorectal Cancer Screening Tests.--Section 
     1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as 
     amended by section 4103(c)(4), is amended--
       (1) in paragraph (1), by striking ``items and services 
     described in section 1861(s)(10)(A)'' and inserting 
     ``preventive services described in subparagraph (A) of 
     section 1861(ddd)(3) that are recommended with a grade of A 
     or B by the United States Preventive Services Task Force for 
     any indication or population and are appropriate for the 
     individual.''; and
       (2) by adding at the end the following new sentence: 
     ``Paragraph (1) of the first sentence of this subsection 
     shall apply with respect to a colorectal cancer screening 
     test regardless of the code that is billed for the 
     establishment of a diagnosis as a result of the test, or for 
     the removal of tissue or other matter or other procedure that 
     is furnished in connection with, as a result of, and in the 
     same clinical encounter as the screening test.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.

[[Page 4321]]



     SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES IN 
                   MEDICARE.

       (a) Authority To Modify or Eliminate Coverage of Certain 
     Preventive Services.--Section 1834 of the Social Security Act 
     (42 U.S.C. 1395m) is amended by adding at the end the 
     following new subsection:
       ``(n) Authority To Modify or Eliminate Coverage of Certain 
     Preventive Services.--Notwithstanding any other provision of 
     this title, effective beginning on January 1, 2010, if the 
     Secretary determines appropriate, the Secretary may--
       ``(1) modify--
       ``(A) the coverage of any preventive service described in 
     subparagraph (A) of section 1861(ddd)(3) to the extent that 
     such modification is consistent with the recommendations of 
     the United States Preventive Services Task Force; and
       ``(B) the services included in the initial preventive 
     physical examination described in subparagraph (B) of such 
     section; and
       ``(2) provide that no payment shall be made under this 
     title for a preventive service described in subparagraph (A) 
     of such section that has not received a grade of A, B, C, or 
     I by such Task Force.''.
       (b) Construction.--Nothing in the amendment made by 
     paragraph (1) shall be construed to affect the coverage of 
     diagnostic or treatment services under title XVIII of the 
     Social Security Act.

     SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR 
                   ELIGIBLE ADULTS IN MEDICAID.

       (a) Clarification of Inclusion of Services.--Section 
     1905(a)(13) of the Social Security Act (42 U.S.C. 
     1396d(a)(13)) is amended to read as follows:
       ``(13) other diagnostic, screening, preventive, and 
     rehabilitative services, including--
       ``(A) any clinical preventive services that are assigned a 
     grade of A or B by the United States Preventive Services Task 
     Force;
       ``(B) with respect to an adult individual, approved 
     vaccines recommended by the Advisory Committee on 
     Immunization Practices (an advisory committee established by 
     the Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention) and their administration; and
       ``(C) any medical or remedial services (provided in a 
     facility, a home, or other setting) recommended by a 
     physician or other licensed practitioner of the healing arts 
     within the scope of their practice under State law, for the 
     maximum reduction of physical or mental disability and 
     restoration of an individual to the best possible functional 
     level;''.
       (b) Increased Fmap.--Section 1905(b) of the Social Security 
     Act (42 U.S.C. 1396d(b)), as amended by sections 
     2001(a)(3)(A) and 2004(c)(1), is amended in the first 
     sentence--
       (1) by striking ``, and (4)'' and inserting ``, (4)''; and
       (2) by inserting before the period the following: ``, and 
     (5) in the case of a State that provides medical assistance 
     for services and vaccines described in subparagraphs (A) and 
     (B) of subsection (a)(13), and prohibits cost-sharing for 
     such services and vaccines, the Federal medical assistance 
     percentage, as determined under this subsection and 
     subsection (y) (without regard to paragraph (1)(C) of such 
     subsection), shall be increased by 1 percentage point with 
     respect to medical assistance for such services and vaccines 
     and for items and services described in subsection 
     (a)(4)(D)''.
       (c) Effective Date.--The amendments made under this section 
     shall take effect on January 1, 2013.

     SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION 
                   SERVICES FOR PREGNANT WOMEN IN MEDICAID.

       (a) Requiring Coverage of Counseling and Pharmacotherapy 
     for Cessation of Tobacco Use by Pregnant Women.--Section 1905 
     of the Social Security Act (42 U.S.C. 1396d), as amended by 
     sections 2001(a)(3)(B) and 2303, is further amended--
       (1) in subsection (a)(4)--
       (A) by striking ``and'' before ``(C)''; and
       (B) by inserting before the semicolon at the end the 
     following new subparagraph: ``; and (D) counseling and 
     pharmacotherapy for cessation of tobacco use by pregnant 
     women (as defined in subsection (bb))''; and
       (2) by adding at the end the following:
       ``(bb)(1) For purposes of this title, the term `counseling 
     and pharmacotherapy for cessation of tobacco use by pregnant 
     women' means diagnostic, therapy, and counseling services and 
     pharmacotherapy (including the coverage of prescription and 
     nonprescription tobacco cessation agents approved by the Food 
     and Drug Administration) for cessation of tobacco use by 
     pregnant women who use tobacco products or who are being 
     treated for tobacco use that is furnished--
       ``(A) by or under the supervision of a physician; or
       ``(B) by any other health care professional who--
       ``(i) is legally authorized to furnish such services under 
     State law (or the State regulatory mechanism provided by 
     State law) of the State in which the services are furnished; 
     and
       ``(ii) is authorized to receive payment for other services 
     under this title or is designated by the Secretary for this 
     purpose.
       ``(2) Subject to paragraph (3), such term is limited to--
       ``(A) services recommended with respect to pregnant women 
     in `Treating Tobacco Use and Dependence: 2008 Update: A 
     Clinical Practice Guideline', published by the Public Health 
     Service in May 2008, or any subsequent modification of such 
     Guideline; and
       ``(B) such other services that the Secretary recognizes to 
     be effective for cessation of tobacco use by pregnant women.
       ``(3) Such term shall not include coverage for drugs or 
     biologicals that are not otherwise covered under this 
     title.''.
       (b) Exception From Optional Restriction Under Medicaid 
     Prescription Drug Coverage.--Section 1927(d)(2)(F) of the 
     Social Security Act (42 U.S.C. 1396r-8(d)(2)(F)), as 
     redesignated by section 2502(a), is amended by inserting 
     before the period at the end the following: ``, except, in 
     the case of pregnant women when recommended in accordance 
     with the Guideline referred to in section 1905(bb)(2)(A), 
     agents approved by the Food and Drug Administration under the 
     over-the-counter monograph process for purposes of promoting, 
     and when used to promote, tobacco cessation''.
       (c) Removal of Cost-Sharing for Counseling and 
     Pharmacotherapy for Cessation of Tobacco Use by Pregnant 
     Women.--
       (1) General cost-sharing limitations.--Section 1916 of the 
     Social Security Act (42 U.S.C. 1396o) is amended in each of 
     subsections (a)(2)(B) and (b)(2)(B) by inserting ``, and 
     counseling and pharmacotherapy for cessation of tobacco use 
     by pregnant women (as defined in section 1905(bb)) and 
     covered outpatient drugs (as defined in subsection (k)(2) of 
     section 1927 and including nonprescription drugs described in 
     subsection (d)(2) of such section) that are prescribed for 
     purposes of promoting, and when used to promote, tobacco 
     cessation by pregnant women in accordance with the Guideline 
     referred to in section 1905(bb)(2)(A)'' after ``complicate 
     the pregnancy''.
       (2) Application to alternative cost-sharing.--Section 
     1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o-
     1(b)(3)(B)(iii)) is amended by inserting ``, and counseling 
     and pharmacotherapy for cessation of tobacco use by pregnant 
     women (as defined in section 1905(bb))'' after ``complicate 
     the pregnancy''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on October 1, 2010.

     SEC. 4108. INCENTIVES FOR PREVENTION OF CHRONIC DISEASES IN 
                   MEDICAID.

       (a) Initiatives.--
       (1) Establishment.--
       (A) In general.--The Secretary shall award grants to States 
     to carry out initiatives to provide incentives to Medicaid 
     beneficiaries who--
       (i) successfully participate in a program described in 
     paragraph (3); and
       (ii) upon completion of such participation, demonstrate 
     changes in health risk and outcomes, including the adoption 
     and maintenance of healthy behaviors by meeting specific 
     targets (as described in subsection (c)(2)).
       (B) Purpose.--The purpose of the initiatives under this 
     section is to test approaches that may encourage behavior 
     modification and determine scalable solutions.
       (2) Duration.--
       (A) Initiation of program; resources.--The Secretary shall 
     awards grants to States beginning on January 1, 2011, or 
     beginning on the date on which the Secretary develops program 
     criteria, whichever is earlier. The Secretary shall develop 
     program criteria for initiatives under this section using 
     relevant evidence-based research and resources, including the 
     Guide to Community Preventive Services, the Guide to Clinical 
     Preventive Services, and the National Registry of Evidence-
     Based Programs and Practices.
       (B) Duration of program.--A State awarded a grant to carry 
     out initiatives under this section shall carry out such 
     initiatives within the 5-year period beginning on January 1, 
     2011, or beginning on the date on which the Secretary 
     develops program criteria, whichever is earlier. Initiatives 
     under this section shall be carried out by a State for a 
     period of not less than 3 years.
       (3) Program described.--
       (A) In general.--A program described in this paragraph is a 
     comprehensive, evidence-based, widely available, and easily 
     accessible program, proposed by the State and approved by the 
     Secretary, that is designed and uniquely suited to address 
     the needs of Medicaid beneficiaries and has demonstrated 
     success in helping individuals achieve one or more of the 
     following:
       (i) Ceasing use of tobacco products.
       (ii) Controlling or reducing their weight.
       (iii) Lowering their cholesterol.
       (iv) Lowering their blood pressure.
       (v) Avoiding the onset of diabetes or, in the case of a 
     diabetic, improving the management of that condition.
       (B) Co-morbidities.--A program under this section may also 
     address co-morbidities (including depression) that are 
     related to any of the conditions described in subparagraph 
     (A).
       (C) Waiver authority.--The Secretary may waive the 
     requirements of section 1902(a)(1) (relating to 
     statewideness) of the Social Security Act for a State awarded 
     a grant to conduct an initiative under this section and shall 
     ensure that a State makes any program described in 
     subparagraph (A) available and accessible to Medicaid 
     beneficiaries.
       (D) Flexibility in implementation.--A State may enter into 
     arrangements with providers participating in Medicaid, 
     community-based organizations, faith-based organizations, 
     public-private partnerships, Indian tribes, or similar 
     entities or organizations to carry out programs described in 
     subparagraph (A).
       (4) Application.--Following the development of program 
     criteria by the Secretary, a State

[[Page 4322]]

     may submit an application, in such manner and containing such 
     information as the Secretary may require, that shall include 
     a proposal for programs described in paragraph (3)(A) and a 
     plan to make Medicaid beneficiaries and providers 
     participating in Medicaid who reside in the State aware and 
     informed about such programs.
       (b) Education and Outreach Campaign.--
       (1) State awareness.--The Secretary shall conduct an 
     outreach and education campaign to make States aware of the 
     grants under this section.
       (2) Provider and beneficiary education.--A State awarded a 
     grant to conduct an initiative under this section shall 
     conduct an outreach and education campaign to make Medicaid 
     beneficiaries and providers participating in Medicaid who 
     reside in the State aware of the programs described in 
     subsection (a)(3) that are to be carried out by the State 
     under the grant.
       (c) Impact.--A State awarded a grant to conduct an 
     initiative under this section shall develop and implement a 
     system to--
       (1) track Medicaid beneficiary participation in the program 
     and validate changes in health risk and outcomes with 
     clinical data, including the adoption and maintenance of 
     health behaviors by such beneficiaries;
       (2) to the extent practicable, establish standards and 
     health status targets for Medicaid beneficiaries 
     participating in the program and measure the degree to which 
     such standards and targets are met;
       (3) evaluate the effectiveness of the program and provide 
     the Secretary with such evaluations;
       (4) report to the Secretary on processes that have been 
     developed and lessons learned from the program; and
       (5) report on preventive services as part of reporting on 
     quality measures for Medicaid managed care programs.
       (d) Evaluations and Reports.--
       (1) Independent assessment.--The Secretary shall enter into 
     a contract with an independent entity or organization to 
     conduct an evaluation and assessment of the initiatives 
     carried out by States under this section, for the purpose of 
     determining--
       (A) the effect of such initiatives on the use of health 
     care services by Medicaid beneficiaries participating in the 
     program;
       (B) the extent to which special populations (including 
     adults with disabilities, adults with chronic illnesses, and 
     children with special health care needs) are able to 
     participate in the program;
       (C) the level of satisfaction of Medicaid beneficiaries 
     with respect to the accessibility and quality of health care 
     services provided through the program; and
       (D) the administrative costs incurred by State agencies 
     that are responsible for administration of the program.
       (2) State reporting.--A State awarded a grant to carry out 
     initiatives under this section shall submit reports to the 
     Secretary, on a semi-annual basis, regarding the programs 
     that are supported by the grant funds. Such report shall 
     include information, as specified by the Secretary, 
     regarding--
       (A) the specific uses of the grant funds;
       (B) an assessment of program implementation and lessons 
     learned from the programs;
       (C) an assessment of quality improvements and clinical 
     outcomes under such programs; and
       (D) estimates of cost savings resulting from such programs.
       (3) Initial report.--Not later than January 1, 2014, the 
     Secretary shall submit to Congress an initial report on such 
     initiatives based on information provided by States through 
     reports required under paragraph (2). The initial report 
     shall include an interim evaluation of the effectiveness of 
     the initiatives carried out with grants awarded under this 
     section and a recommendation regarding whether funding for 
     expanding or extending the initiatives should be extended 
     beyond January 1, 2016.
       (4) Final report.--Not later than July 1, 2016, the 
     Secretary shall submit to Congress a final report on the 
     program that includes the results of the independent 
     assessment required under paragraph (1), together with 
     recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.
       (e) No Effect on Eligibility for, or Amount of, Medicaid or 
     Other Benefits.--Any incentives provided to a Medicaid 
     beneficiary participating in a program described in 
     subsection (a)(3) shall not be taken into account for 
     purposes of determining the beneficiary's eligibility for, or 
     amount of, benefits under the Medicaid program or any program 
     funded in whole or in part with Federal funds.
       (f) Funding.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated for the 5-year 
     period beginning on January 1, 2011, $100,000,000 to the 
     Secretary to carry out this section. Amounts appropriated 
     under this subsection shall remain available until expended.
       (g) Definitions.--In this section:
       (1) Medicaid beneficiary.--The term ``Medicaid 
     beneficiary'' means an individual who is eligible for medical 
     assistance under a State plan or waiver under title XIX of 
     the Social Security Act (42 U.S.C. 1396 et seq.) and is 
     enrolled in such plan or waiver.
       (2) State.--The term ``State'' has the meaning given that 
     term for purposes of title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).

               Subtitle C--Creating Healthier Communities

     SEC. 4201. COMMUNITY TRANSFORMATION GRANTS.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Director of the Centers for Disease Control and 
     Prevention (referred to in this section as the ``Director''), 
     shall award competitive grants to State and local 
     governmental agencies and community-based organizations for 
     the implementation, evaluation, and dissemination of 
     evidence-based community preventive health activities in 
     order to reduce chronic disease rates, prevent the 
     development of secondary conditions, address health 
     disparities, and develop a stronger evidence-base of 
     effective prevention programming.
       (b) Eligibility.--To be eligible to receive a grant under 
     subsection (a), an entity shall--
       (1) be--
       (A) a State governmental agency;
       (B) a local governmental agency;
       (C) a national network of community-based organizations;
       (D) a State or local non-profit organization; or
       (E) an Indian tribe; and
       (2) submit to the Director an application at such time, in 
     such a manner, and containing such information as the 
     Director may require, including a description of the program 
     to be carried out under the grant; and
       (3) demonstrate a history or capacity, if funded, to 
     develop relationships necessary to engage key stakeholders 
     from multiple sectors within and beyond health care and 
     across a community, such as healthy futures corps and health 
     care providers.
       (c) Use of Funds.--
       (1) In general.--An eligible entity shall use amounts 
     received under a grant under this section to carry out 
     programs described in this subsection.
       (2) Community transformation plan.--
       (A) In general.--An eligible entity that receives a grant 
     under this section shall submit to the Director (for 
     approval) a detailed plan that includes the policy, 
     environmental, programmatic, and as appropriate 
     infrastructure changes needed to promote healthy living and 
     reduce disparities.
       (B) Activities.--Activities within the plan may focus on 
     (but not be limited to)--
       (i) creating healthier school environments, including 
     increasing healthy food options, physical activity 
     opportunities, promotion of healthy lifestyle, emotional 
     wellness, and prevention curricula, and activities to prevent 
     chronic diseases;
       (ii) creating the infrastructure to support active living 
     and access to nutritious foods in a safe environment;
       (iii) developing and promoting programs targeting a variety 
     of age levels to increase access to nutrition, physical 
     activity and smoking cessation, improve social and emotional 
     wellness, enhance safety in a community, or address any other 
     chronic disease priority area identified by the grantee;
       (iv) assessing and implementing worksite wellness 
     programming and incentives;
       (v) working to highlight healthy options at restaurants and 
     other food venues;
       (vi) prioritizing strategies to reduce racial and ethnic 
     disparities, including social, economic, and geographic 
     determinants of health; and
       (vii) addressing special populations needs, including all 
     age groups and individuals with disabilities, and individuals 
     in both urban and rural areas.
       (3) Community-based prevention health activities.--
       (A) In general.--An eligible entity shall use amounts 
     received under a grant under this section to implement a 
     variety of programs, policies, and infrastructure 
     improvements to promote healthier lifestyles.
       (B) Activities.--An eligible entity shall implement 
     activities detailed in the community transformation plan 
     under paragraph (2).
       (C) In-kind support.--An eligible entity may provide in-
     kind resources such as staff, equipment, or office space in 
     carrying out activities under this section.
       (4) Evaluation.--
       (A) In general.--An eligible entity shall use amounts 
     provided under a grant under this section to conduct 
     activities to measure changes in the prevalence of chronic 
     disease risk factors among community members participating in 
     preventive health activities
       (B) Types of measures.--In carrying out subparagraph (A), 
     the eligible entity shall, with respect to residents in the 
     community, measure--
       (i) changes in weight;
       (ii) changes in proper nutrition;
       (iii) changes in physical activity;
       (iv) changes in tobacco use prevalence;
       (v) changes in emotional well-being and overall mental 
     health;
       (vi) other factors using community-specific data from the 
     Behavioral Risk Factor Surveillance Survey; and
       (vii) other factors as determined by the Secretary.
       (C) Reporting.--An eligible entity shall annually submit to 
     the Director a report containing an evaluation of activities 
     carried out under the grant.
       (5) Dissemination.--A grantee under this section shall--
       (A) meet at least annually in regional or national meetings 
     to discuss challenges, best practices, and lessons learned 
     with respect to activities carried out under the grant; and
       (B) develop models for the replication of successful 
     programs and activities and the mentoring of other eligible 
     entities.

[[Page 4323]]

       (d) Training.--
       (1) In general.--The Director shall develop a program to 
     provide training for eligible entities on effective 
     strategies for the prevention and control of chronic disease 
     and the link between physical, emotional, and social well-
     being.
       (2) Community transformation plan.--The Director shall 
     provide appropriate feedback and technical assistance to 
     grantees to establish community transformation plans
       (3) Evaluation.--The Director shall provide a literature 
     review and framework for the evaluation of programs conducted 
     as part of the grant program under this section, in addition 
     to working with academic institutions or other entities with 
     expertise in outcome evaluation.
       (e) Prohibition.--A grantee shall not use funds provided 
     under a grant under this section to create video games or to 
     carry out any other activities that may lead to higher rates 
     of obesity or inactivity.
       (f) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section, such sums as 
     may be necessary for each fiscal years 2010 through 2014.

     SEC. 4202. HEALTHY AGING, LIVING WELL; EVALUATION OF 
                   COMMUNITY-BASED PREVENTION AND WELLNESS 
                   PROGRAMS FOR MEDICARE BENEFICIARIES.

       (a) Healthy Aging, Living Well.--
       (1) In general.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall award grants to State or local health 
     departments and Indian tribes to carry out 5-year pilot 
     programs to provide public health community interventions, 
     screenings, and where necessary, clinical referrals for 
     individuals who are between 55 and 64 years of age.
       (2) Eligibility.--To be eligible to receive a grant under 
     paragraph (1), an entity shall--
       (A) be--
       (i) a State health department;
       (ii) a local health department; or
       (iii) an Indian tribe;
       (B) submit to the Secretary an application at such time, in 
     such manner, and containing such information as the Secretary 
     may require including a description of the program to be 
     carried out under the grant;
       (C) design a strategy for improving the health of the 55-
     to-64 year-old population through community-based public 
     health interventions; and
       (D) demonstrate the capacity, if funded, to develop the 
     relationships necessary with relevant health agencies, health 
     care providers, community-based organizations, and insurers 
     to carry out the activities described in paragraph (3), such 
     relationships to include the identification of a community-
     based clinical partner, such as a community health center or 
     rural health clinic.
       (3) Use of funds.--
       (A) In general.--A State or local health department shall 
     use amounts received under a grant under this subsection to 
     carry out a program to provide the services described in this 
     paragraph to individuals who are between 55 and 64 years of 
     age.
       (B) Public health interventions.--
       (i) In general.--In developing and implementing such 
     activities, a grantee shall collaborate with the Centers for 
     Disease Control and Prevention and the Administration on 
     Aging, and relevant local agencies and organizations.
       (ii) Types of intervention activities.--Intervention 
     activities conducted under this subparagraph may include 
     efforts to improve nutrition, increase physical activity, 
     reduce tobacco use and substance abuse, improve mental 
     health, and promote healthy lifestyles among the target 
     population.
       (C) Community preventive screenings.--
       (i) In general.--In addition to community-wide public 
     health interventions, a State or local health department 
     shall use amounts received under a grant under this 
     subsection to conduct ongoing health screening to identify 
     risk factors for cardiovascular disease, cancer, stroke, and 
     diabetes among individuals in both urban and rural areas who 
     are between 55 and 64 years of age.
       (ii) Types of screening activities.--Screening activities 
     conducted under this subparagraph may include--

       (I) mental health/behavioral health and substance use 
     disorders;
       (II) physical activity, smoking, and nutrition; and
       (III) any other measures deemed appropriate by the 
     Secretary.

       (iii) Monitoring.--Grantees under this section shall 
     maintain records of screening results under this subparagraph 
     to establish the baseline data for monitoring the targeted 
     population
       (D) Clinical referral/treatment for chronic diseases.--
       (i) In general.--A State or local health department shall 
     use amounts received under a grant under this subsection to 
     ensure that individuals between 55 and 64 years of age who 
     are found to have chronic disease risk factors through the 
     screening activities described in subparagraph (C)(ii), 
     receive clinical referral/treatment for follow-up services to 
     reduce such risk.
       (ii) Mechanism.--

       (I) Identification and determination of status.--With 
     respect to each individual with risk factors for or having 
     heart disease, stroke, diabetes, or any other condition for 
     which such individual was screened under subparagraph (C), a 
     grantee under this section shall determine whether or not 
     such individual is covered under any public or private health 
     insurance program.
       (II) Insured individuals.--An individual determined to be 
     covered under a health insurance program under subclause (I) 
     shall be referred by the grantee to the existing providers 
     under such program or, if such individual does not have a 
     current provider, to a provider who is in-network with 
     respect to the program involved.
       (III) Uninsured individuals.--With respect to an individual 
     determined to be uninsured under subclause (I), the grantee's 
     community-based clinical partner described in paragraph 
     (4)(D) shall assist the individual in determining eligibility 
     for available public coverage options and identify other 
     appropriate community health care resources and assistance 
     programs.

       (iii) Public health intervention program.--A State or local 
     health department shall use amounts received under a grant 
     under this subsection to enter into contracts with community 
     health centers or rural health clinics and mental health and 
     substance use disorder service providers to assist in the 
     referral/treatment of at risk patients to community resources 
     for clinical follow-up and help determine eligibility for 
     other public programs.
       (E) Grantee evaluation.--An eligible entity shall use 
     amounts provided under a grant under this subsection to 
     conduct activities to measure changes in the prevalence of 
     chronic disease risk factors among participants.
       (4) Pilot program evaluation.--The Secretary shall conduct 
     an annual evaluation of the effectiveness of the pilot 
     program under this subsection. In determining such 
     effectiveness, the Secretary shall consider changes in the 
     prevalence of uncontrolled chronic disease risk factors among 
     new Medicare enrollees (or individuals nearing enrollment, 
     including those who are 63 and 64 years of age) who reside in 
     States or localities receiving grants under this section as 
     compared with national and historical data for those States 
     and localities for the same population.
       (5) Authorization of appropriations.--There are authorized 
     to be appropriated to carry out this subsection, such sums as 
     may be necessary for each of fiscal years 2010 through 2014.
       (b) Evaluation and Plan for Community-Based Prevention and 
     Wellness Programs for Medicare Beneficiaries.--
       (1) In general.--The Secretary shall conduct an evaluation 
     of community-based prevention and wellness programs and 
     develop a plan for promoting healthy lifestyles and chronic 
     disease self-management for Medicare beneficiaries.
       (2) Medicare evaluation of prevention and wellness 
     programs.--
       (A) In general.--The Secretary shall evaluate community 
     prevention and wellness programs including those that are 
     sponsored by the Administration on Aging, are evidence-based, 
     and have demonstrated potential to help Medicare 
     beneficiaries (particularly beneficiaries that have attained 
     65 years of age) reduce their risk of disease, disability, 
     and injury by making healthy lifestyle choices, including 
     exercise, diet, and self-management of chronic diseases.
       (B) Evaluation.--The evaluation under subparagraph (A) 
     shall consist of the following:
       (i) Evidence review.--The Secretary shall review available 
     evidence, literature, best practices, and resources that are 
     relevant to programs that promote healthy lifestyles and 
     reduce risk factors for the Medicare population. The 
     Secretary may determine the scope of the evidence review and 
     such issues to be considered, which shall include, at a 
     minimum--

       (I) physical activity, nutrition, and obesity;
       (II) falls;
       (III) chronic disease self-management; and
       (IV) mental health.

       (ii) Independent evaluation of evidence-based community 
     prevention and wellness programs.--The Administrator of the 
     Centers for Medicare & Medicaid Services, in consultation 
     with the Assistant Secretary for Aging, shall, to the extent 
     feasible and practicable, conduct an evaluation of existing 
     community prevention and wellness programs that are sponsored 
     by the Administration on Aging to assess the extent to which 
     Medicare beneficiaries who participate in such programs--

       (I) reduce their health risks, improve their health 
     outcomes, and adopt and maintain healthy behaviors;
       (II) improve their ability to manage their chronic 
     conditions; and
       (III) reduce their utilization of health services and 
     associated costs under the Medicare program for conditions 
     that are amenable to improvement under such programs.

       (3) Report.--Not later than September 30, 2013, the 
     Secretary shall submit to Congress a report that includes--
       (A) recommendations for such legislation and administrative 
     action as the Secretary determines appropriate to promote 
     healthy lifestyles and chronic disease self-management for 
     Medicare beneficiaries;
       (B) any relevant findings relating to the evidence review 
     under paragraph (2)(B)(i); and
       (C) the results of the evaluation under paragraph 
     (2)(B)(ii).
       (4) Funding.--For purposes of carrying out this subsection, 
     the Secretary shall provide for the transfer, from the 
     Federal Hospital Insurance Trust Fund under section 1817 of 
     the Social Security Act (42 U.S.C. 1395i) and the Federal 
     Supplemental Medical Insurance Trust Fund under section 1841 
     of such Act (42 U.S.C. 1395t), in such proportion as the 
     Secretary determines appropriate, of $50,000,000 to the 
     Centers for Medicare & Medicaid Services Program Management 
     Account. Amounts transferred under the preceding sentence 
     shall remain available until expended.
       (5) Administration.--Chapter 35 of title 44, United States 
     Code shall not apply to the this subsection.

[[Page 4324]]

       (6) Medicare beneficiary.--In this subsection, the term 
     ``Medicare beneficiary'' means an individual who is entitled 
     to benefits under part A of title XVIII of the Social 
     Security Act and enrolled under part B of such title.

     SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO WELLNESS 
                   FOR INDIVIDUALS WITH DISABILITIES.

       Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et 
     seq.) is amended by adding at the end of the following:

     ``SEC. 510. ESTABLISHMENT OF STANDARDS FOR ACCESSIBLE MEDICAL 
                   DIAGNOSTIC EQUIPMENT.

       ``(a) Standards.--Not later than 24 months after the date 
     of enactment of the Affordable Health Choices Act, the 
     Architectural and Transportation Barriers Compliance Board 
     shall, in consultation with the Commissioner of the Food and 
     Drug Administration, promulgate regulatory standards in 
     accordance with the Administrative Procedure Act (2 U.S.C. 
     551 et seq.) setting forth the minimum technical criteria for 
     medical diagnostic equipment used in (or in conjunction with) 
     physician's offices, clinics, emergency rooms, hospitals, and 
     other medical settings. The standards shall ensure that such 
     equipment is accessible to, and usable by, individuals with 
     accessibility needs, and shall allow independent entry to, 
     use of, and exit from the equipment by such individuals to 
     the maximum extent possible.
       ``(b) Medical Diagnostic Equipment Covered.--The standards 
     issued under subsection (a) for medical diagnostic equipment 
     shall apply to equipment that includes examination tables, 
     examination chairs (including chairs used for eye 
     examinations or procedures, and dental examinations or 
     procedures), weight scales, mammography equipment, x-ray 
     machines, and other radiological equipment commonly used for 
     diagnostic purposes by health professionals.
       ``(c) Review and Amendment.--The Architectural and 
     Transportation Barriers Compliance Board, in consultation 
     with the Commissioner of the Food and Drug Administration, 
     shall periodically review and, as appropriate, amend the 
     standards in accordance with the Administrative Procedure Act 
     (2 U.S.C. 551 et seq.).''.

     SEC. 4204. IMMUNIZATIONS.

       (a) State Authority To Purchase Recommended Vaccines for 
     Adults.--Section 317 of the Public Health Service Act (42 
     U.S.C. 247b) is amended by adding at the end the following:
       ``(l) Authority To Purchase Recommended Vaccines for 
     Adults.--
       ``(1) In general.--The Secretary may negotiate and enter 
     into contracts with manufacturers of vaccines for the 
     purchase and delivery of vaccines for adults as provided for 
     under subsection (e).
       ``(2) State purchase.--A State may obtain additional 
     quantities of such adult vaccines (subject to amounts 
     specified to the Secretary by the State in advance of 
     negotiations) through the purchase of vaccines from 
     manufacturers at the applicable price negotiated by the 
     Secretary under this subsection.''.
       (b) Demonstration Program To Improve Immunization 
     Coverage.--Section 317 of the Public Health Service Act (42 
     U.S.C. 247b), as amended by subsection (a), is further 
     amended by adding at the end the following:
       ``(m) Demonstration Program To Improve Immunization 
     Coverage.--
       ``(1) In general.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a demonstration program to award grants to 
     States to improve the provision of recommended immunizations 
     for children, adolescents, and adults through the use of 
     evidence-based, population-based interventions for high-risk 
     populations.
       ``(2) State plan.--To be eligible for a grant under 
     paragraph (1), a State shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require, including a State 
     plan that describes the interventions to be implemented under 
     the grant and how such interventions match with local needs 
     and capabilities, as determined through consultation with 
     local authorities.
       ``(3) Use of funds.--Funds received under a grant under 
     this subsection shall be used to implement interventions that 
     are recommended by the Task Force on Community Preventive 
     Services (as established by the Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention) 
     or other evidence-based interventions, including--
       ``(A) providing immunization reminders or recalls for 
     target populations of clients, patients, and consumers;
       ``(B) educating targeted populations and health care 
     providers concerning immunizations in combination with one or 
     more other interventions;
       ``(C) reducing out-of-pocket costs for families for 
     vaccines and their administration;
       ``(D) carrying out immunization-promoting strategies for 
     participants or clients of public programs, including 
     assessments of immunization status, referrals to health care 
     providers, education, provision of on-site immunizations, or 
     incentives for immunization;
       ``(E) providing for home visits that promote immunization 
     through education, assessments of need, referrals, provision 
     of immunizations, or other services;
       ``(F) providing reminders or recalls for immunization 
     providers;
       ``(G) conducting assessments of, and providing feedback to, 
     immunization providers;
       ``(H) any combination of one or more interventions 
     described in this paragraph; or
       ``(I) immunization information systems to allow all States 
     to have electronic databases for immunization records.
       ``(4) Consideration.--In awarding grants under this 
     subsection, the Secretary shall consider any reviews or 
     recommendations of the Task Force on Community Preventive 
     Services.
       ``(5) Evaluation.--Not later than 3 years after the date on 
     which a State receives a grant under this subsection, the 
     State shall submit to the Secretary an evaluation of progress 
     made toward improving immunization coverage rates among high-
     risk populations within the State.
       ``(6) Report to congress.--Not later than 4 years after the 
     date of enactment of the Affordable Health Choices Act, the 
     Secretary shall submit to Congress a report concerning the 
     effectiveness of the demonstration program established under 
     this subsection together with recommendations on whether to 
     continue and expand such program.
       ``(7) Authorization of appropriations.--There is authorized 
     to be appropriated to carry out this subsection, such sums as 
     may be necessary for each of fiscal years 2010 through 
     2014.''.
       (c) Reauthorization of Immunization Program.--Section 
     317(j) of the Public Health Service Act (42 U.S.C. 247b(j)) 
     is amended--
       (1) in paragraph (1), by striking ``for each of the fiscal 
     years 1998 through 2005''; and
       (2) in paragraph (2), by striking ``after October 1, 
     1997,''.
       (d) Rule of Construction Regarding Access to 
     Immunizations.--Nothing in this section (including the 
     amendments made by this section), or any other provision of 
     this Act (including any amendments made by this Act) shall be 
     construed to decrease children's access to immunizations.
       (e) GAO Study and Report on Medicare Beneficiary Access to 
     Vaccines.--
       (1) Study.--The Comptroller General of the United States 
     (in this section referred to as the ``Comptroller General'') 
     shall conduct a study on the ability of Medicare 
     beneficiaries who were 65 years of age or older to access 
     routinely recommended vaccines covered under the prescription 
     drug program under part D of title XVIII of the Social 
     Security Act over the period since the establishment of such 
     program. Such study shall include the following:
       (A) An analysis and determination of--
       (i) the number of Medicare beneficiaries who were 65 years 
     of age or older and were eligible for a routinely recommended 
     vaccination that was covered under part D;
       (ii) the number of such beneficiaries who actually received 
     a routinely recommended vaccination that was covered under 
     part D; and
       (iii) any barriers to access by such beneficiaries to 
     routinely recommended vaccinations that were covered under 
     part D.
       (B) A summary of the findings and recommendations by 
     government agencies, departments, and advisory bodies (as 
     well as relevant professional organizations) on the impact of 
     coverage under part D of routinely recommended adult 
     immunizations for access to such immunizations by Medicare 
     beneficiaries.
       (2) Report.--Not later than June 1, 2011, the Comptroller 
     General shall submit to the appropriate committees of 
     jurisdiction of the House of Representatives and the Senate a 
     report containing the results of the study conducted under 
     paragraph (1), together with recommendations for such 
     legislation and administrative action as the Comptroller 
     General determines appropriate.
       (3) Funding.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated $1,000,000 for 
     fiscal year 2010 to carry out this subsection.

     SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN 
                   RESTAURANTS.

       (a) Technical Amendments.--Section 403(q)(5)(A) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) 
     is amended--
       (1) in subitem (i), by inserting at the beginning ``except 
     as provided in clause (H)(ii)(III),''; and
       (2) in subitem (ii), by inserting at the beginning ``except 
     as provided in clause (H)(ii)(III),''.
       (b) Labeling Requirements.--Section 403(q)(5) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is 
     amended by adding at the end the following:
       ``(H) Restaurants, Retail Food Establishments, and Vending 
     Machines.--
       ``(i) General requirements for restaurants and similar 
     retail food establishments.--Except for food described in 
     subclause (vii), in the case of food that is a standard menu 
     item that is offered for sale in a restaurant or similar 
     retail food establishment that is part of a chain with 20 or 
     more locations doing business under the same name (regardless 
     of the type of ownership of the locations) and offering for 
     sale substantially the same menu items, the restaurant or 
     similar retail food establishment shall disclose the 
     information described in subclauses (ii) and (iii).
       ``(ii) Information required to be disclosed by restaurants 
     and retail food establishments.--Except as provided in 
     subclause (vii), the restaurant or similar retail food 
     establishment shall disclose in a clear and conspicuous 
     manner--
       ``(I)(aa) in a nutrient content disclosure statement 
     adjacent to the name of the standard menu item, so as to be 
     clearly associated with the standard menu item, on the menu 
     listing the item for sale, the number of calories contained 
     in the standard menu item, as usually prepared and offered 
     for sale; and
       ``(bb) a succinct statement concerning suggested daily 
     caloric intake, as specified by the Secretary by regulation 
     and posted prominently

[[Page 4325]]

     on the menu and designed to enable the public to understand, 
     in the context of a total daily diet, the significance of the 
     caloric information that is provided on the menu;
       ``(II)(aa) in a nutrient content disclosure statement 
     adjacent to the name of the standard menu item, so as to be 
     clearly associated with the standard menu item, on the menu 
     board, including a drive-through menu board, the number of 
     calories contained in the standard menu item, as usually 
     prepared and offered for sale; and
       ``(bb) a succinct statement concerning suggested daily 
     caloric intake, as specified by the Secretary by regulation 
     and posted prominently on the menu board, designed to enable 
     the public to understand, in the context of a total daily 
     diet, the significance of the nutrition information that is 
     provided on the menu board;
       ``(III) in a written form, available on the premises of the 
     restaurant or similar retail establishment and to the 
     consumer upon request, the nutrition information required 
     under clauses (C) and (D) of subparagraph (1); and
       ``(IV) on the menu or menu board, a prominent, clear, and 
     conspicuous statement regarding the availability of the 
     information described in item (III).
       ``(iii) Self-service food and food on display.--Except as 
     provided in subclause (vii), in the case of food sold at a 
     salad bar, buffet line, cafeteria line, or similar self-
     service facility, and for self-service beverages or food that 
     is on display and that is visible to customers, a restaurant 
     or similar retail food establishment shall place adjacent to 
     each food offered a sign that lists calories per displayed 
     food item or per serving.
       ``(iv) Reasonable basis.--For the purposes of this clause, 
     a restaurant or similar retail food establishment shall have 
     a reasonable basis for its nutrient content disclosures, 
     including nutrient databases, cookbooks, laboratory analyses, 
     and other reasonable means, as described in section 101.10 of 
     title 21, Code of Federal Regulations (or any successor 
     regulation) or in a related guidance of the Food and Drug 
     Administration.
       ``(v) Menu variability and combination meals.--The 
     Secretary shall establish by regulation standards for 
     determining and disclosing the nutrient content for standard 
     menu items that come in different flavors, varieties, or 
     combinations, but which are listed as a single menu item, 
     such as soft drinks, ice cream, pizza, doughnuts, or 
     children's combination meals, through means determined by the 
     Secretary, including ranges, averages, or other methods.
       ``(vi) Additional information.--If the Secretary determines 
     that a nutrient, other than a nutrient required under 
     subclause (ii)(III), should be disclosed for the purpose of 
     providing information to assist consumers in maintaining 
     healthy dietary practices, the Secretary may require, by 
     regulation, disclosure of such nutrient in the written form 
     required under subclause (ii)(III).
       ``(vii) Nonapplicability to certain food.--
       ``(I) In general.--Subclauses (i) through (vi) do not apply 
     to--
       ``(aa) items that are not listed on a menu or menu board 
     (such as condiments and other items placed on the table or 
     counter for general use);
       ``(bb) daily specials, temporary menu items appearing on 
     the menu for less than 60 days per calendar year, or custom 
     orders; or
       ``(cc) such other food that is part of a customary market 
     test appearing on the menu for less than 90 days, under terms 
     and conditions established by the Secretary.
       ``(II) Written forms.--Subparagraph (5)(C) shall apply to 
     any regulations promulgated under subclauses (ii)(III) and 
     (vi).
       ``(viii) Vending machines.--
       ``(I) In general.--In the case of an article of food sold 
     from a vending machine that--
       ``(aa) does not permit a prospective purchaser to examine 
     the Nutrition Facts Panel before purchasing the article or 
     does not otherwise provide visible nutrition information at 
     the point of purchase; and
       ``(bb) is operated by a person who is engaged in the 
     business of owning or operating 20 or more vending machines,

     the vending machine operator shall provide a sign in close 
     proximity to each article of food or the selection button 
     that includes a clear and conspicuous statement disclosing 
     the number of calories contained in the article.
       ``(ix) Voluntary provision of nutrition information.--
       ``(I) In general.--An authorized official of any restaurant 
     or similar retail food establishment or vending machine 
     operator not subject to the requirements of this clause may 
     elect to be subject to the requirements of such clause, by 
     registering biannually the name and address of such 
     restaurant or similar retail food establishment or vending 
     machine operator with the Secretary, as specified by the 
     Secretary by regulation.
       ``(II) Registration.--Within 120 days of enactment of this 
     clause, the Secretary shall publish a notice in the Federal 
     Register specifying the terms and conditions for 
     implementation of item (I), pending promulgation of 
     regulations.
       ``(III) Rule of construction.--Nothing in this subclause 
     shall be construed to authorize the Secretary to require an 
     application, review, or licensing process for any entity to 
     register with the Secretary, as described in such item.
       ``(x) Regulations.--
       ``(I) Proposed regulation.--Not later than 1 year after the 
     date of enactment of this clause, the Secretary shall 
     promulgate proposed regulations to carry out this clause.
       ``(II) Contents.--In promulgating regulations, the 
     Secretary shall--
       ``(aa) consider standardization of recipes and methods of 
     preparation, reasonable variation in serving size and 
     formulation of menu items, space on menus and menu boards, 
     inadvertent human error, training of food service workers, 
     variations in ingredients, and other factors, as the 
     Secretary determines; and
       ``(bb) specify the format and manner of the nutrient 
     content disclosure requirements under this subclause.
       ``(III) Reporting.--The Secretary shall submit to the 
     Committee on Health, Education, Labor, and Pensions of the 
     Senate and the Committee on Energy and Commerce of the House 
     of Representatives a quarterly report that describes the 
     Secretary's progress toward promulgating final regulations 
     under this subparagraph.
       ``(xi) Definition.--In this clause, the term `menu' or 
     `menu board' means the primary writing of the restaurant or 
     other similar retail food establishment from which a consumer 
     makes an order selection.''
       (c) National Uniformity.--Section 403A(a)(4) of the Federal 
     Food, Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is 
     amended by striking ``except a requirement for nutrition 
     labeling of food which is exempt under subclause (i) or (ii) 
     of section 403(q)(5)(A)'' and inserting ``except that this 
     paragraph does not apply to food that is offered for sale in 
     a restaurant or similar retail food establishment that is not 
     part of a chain with 20 or more locations doing business 
     under the same name (regardless of the type of ownership of 
     the locations) and offering for sale substantially the same 
     menu items unless such restaurant or similar retail food 
     establishment complies with the voluntary provision of 
     nutrition information requirements under section 
     403(q)(5)(H)(ix)''.
       (d) Rule of Construction.--Nothing in the amendments made 
     by this section shall be construed--
       (1) to preempt any provision of State or local law, unless 
     such provision establishes or continues into effect nutrient 
     content disclosures of the type required under section 
     403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as 
     added by subsection (b)) and is expressly preempted under 
     subsection (a)(4) of such section;
       (2) to apply to any State or local requirement respecting a 
     statement in the labeling of food that provides for a warning 
     concerning the safety of the food or component of the food; 
     or
       (3) except as provided in section 403(q)(5)(H)(ix) of the 
     Federal Food, Drug, and Cosmetic Act (as added by subsection 
     (b)), to apply to any restaurant or similar retail food 
     establishment other than a restaurant or similar retail food 
     establishment described in section 403(q)(5)(H)(i) of such 
     Act.

     SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED 
                   WELLNESS PLAN.

       Section 330 of the Public Health Service Act (42 U.S.C. 
     245b) is amended by adding at the end the following:
       ``(s) Demonstration Program for Individualized Wellness 
     Plans.--
       ``(1) In general.--The Secretary shall establish a pilot 
     program to test the impact of providing at-risk populations 
     who utilize community health centers funded under this 
     section an individualized wellness plan that is designed to 
     reduce risk factors for preventable conditions as identified 
     by a comprehensive risk-factor assessment.
       ``(2) Agreements.--The Secretary shall enter into 
     agreements with not more than 10 community health centers 
     funded under this section to conduct activities under the 
     pilot program under paragraph (1).
       ``(3) Wellness plans.--
       ``(A) In general.--An individualized wellness plan prepared 
     under the pilot program under this subsection may include one 
     or more of the following as appropriate to the individual's 
     identified risk factors:
       ``(i) Nutritional counseling.
       ``(ii) A physical activity plan.
       ``(iii) Alcohol and smoking cessation counseling and 
     services.
       ``(iv) Stress management.
       ``(v) Dietary supplements that have health claims approved 
     by the Secretary.
       ``(vi) Compliance assistance provided by a community health 
     center employee.
       ``(B) Risk factors.--Wellness plan risk factors shall 
     include--
       ``(i) weight;
       ``(ii) tobacco and alcohol use;
       ``(iii) exercise rates;
       ``(iv) nutritional status; and
       ``(v) blood pressure.
       ``(C) Comparisons.--Individualized wellness plans shall 
     make comparisons between the individual involved and a 
     control group of individuals with respect to the risk factors 
     described in subparagraph (B).
       ``(4) Authorization of appropriations.--There is authorized 
     to be appropriated to carry out this subsection, such sums as 
     may be necessary.''.

     SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS.

       Section 7 of the Fair Labor Standards Act of 1938 (29 
     U.S.C. 207) is amended by adding at the end the following:
       ``(r)(1) An employer shall provide--
       ``(A) a reasonable break time for an employee to express 
     breast milk for her nursing child for 1 year after the 
     child's birth each time such employee has need to express the 
     milk; and
       ``(B) a place, other than a bathroom, that is shielded from 
     view and free from intrusion from

[[Page 4326]]

     coworkers and the public, which may be used by an employee to 
     express breast milk.
       ``(2) An employer shall not be required to compensate an 
     employee receiving reasonable break time under paragraph (1) 
     for any work time spent for such purpose.
       ``(3) An employer that employs less than 50 employees shall 
     not be subject to the requirements of this subsection, if 
     such requirements would impose an undue hardship by causing 
     the employer significant difficulty or expense when 
     considered in relation to the size, financial resources, 
     nature, or structure of the employer's business.
       ``(4) Nothing in this subsection shall preempt a State law 
     that provides greater protections to employees than the 
     protections provided for under this subsection.''.

    Subtitle D--Support for Prevention and Public Health Innovation

     SEC. 4301. RESEARCH ON OPTIMIZING THE DELIVERY OF PUBLIC 
                   HEALTH SERVICES.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall provide funding for research in the area of 
     public health services and systems.
       (b) Requirements of Research.--Research supported under 
     this section shall include--
       (1) examining evidence-based practices relating to 
     prevention, with a particular focus on high priority areas as 
     identified by the Secretary in the National Prevention 
     Strategy or Healthy People 2020, and including comparing 
     community-based public health interventions in terms of 
     effectiveness and cost;
       (2) analyzing the translation of interventions from 
     academic settings to real world settings; and
       (3) identifying effective strategies for organizing, 
     financing, or delivering public health services in real world 
     community settings, including comparing State and local 
     health department structures and systems in terms of 
     effectiveness and cost.
       (c) Existing Partnerships.--Research supported under this 
     section shall be coordinated with the Community Preventive 
     Services Task Force and carried out by building on existing 
     partnerships within the Federal Government while also 
     considering initiatives at the State and local levels and in 
     the private sector.
       (d) Annual Report.--The Secretary shall, on an annual 
     basis, submit to Congress a report concerning the activities 
     and findings with respect to research supported under this 
     section.

     SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION 
                   AND ANALYSIS.

       (a) Uniform Categories and Collection Requirements.--The 
     Public Health Service Act (42 U.S.C. 201 et seq.) is amended 
     by adding at the end the following:

          ``TITLE XXXI--DATA COLLECTION, ANALYSIS, AND QUALITY

     ``SEC. 3101. DATA COLLECTION, ANALYSIS, AND QUALITY.

       ``(a) Data Collection.--
       ``(1) In general.--The Secretary shall ensure that, by not 
     later than 2 years after the date of enactment of this title, 
     any federally conducted or supported health care or public 
     health program, activity or survey (including Current 
     Population Surveys and American Community Surveys conducted 
     by the Bureau of Labor Statistics and the Bureau of the 
     Census) collects and reports, to the extent practicable--
       ``(A) data on race, ethnicity, sex, primary language, and 
     disability status for applicants, recipients, or 
     participants;
       ``(B) data at the smallest geographic level such as State, 
     local, or institutional levels if such data can be 
     aggregated;
       ``(C) sufficient data to generate statistically reliable 
     estimates by racial, ethnic, sex, primary language, and 
     disability status subgroups for applicants, recipients or 
     participants using, if needed, statistical oversamples of 
     these subpopulations; and
       ``(D) any other demographic data as deemed appropriate by 
     the Secretary regarding health disparities.
       ``(2) Collection standards.--In collecting data described 
     in paragraph (1), the Secretary or designee shall--
       ``(A) use Office of Management and Budget standards, at a 
     minimum, for race and ethnicity measures;
       ``(B) develop standards for the measurement of sex, primary 
     language, and disability status;
       ``(C) develop standards for the collection of data 
     described in paragraph (1) that, at a minimum--
       ``(i) collects self-reported data by the applicant, 
     recipient, or participant; and
       ``(ii) collects data from a parent or legal guardian if the 
     applicant, recipient, or participant is a minor or legally 
     incapacitated;
       ``(D) survey health care providers and establish other 
     procedures in order to assess access to care and treatment 
     for individuals with disabilities and to identify--
       ``(i) locations where individuals with disabilities access 
     primary, acute (including intensive), and long-term care;
       ``(ii) the number of providers with accessible facilities 
     and equipment to meet the needs of the individuals with 
     disabilities, including medical diagnostic equipment that 
     meets the minimum technical criteria set forth in section 510 
     of the Rehabilitation Act of 1973; and
       ``(iii) the number of employees of health care providers 
     trained in disability awareness and patient care of 
     individuals with disabilities; and
       ``(E) require that any reporting requirement imposed for 
     purposes of measuring quality under any ongoing or federally 
     conducted or supported health care or public health program, 
     activity, or survey includes requirements for the collection 
     of data on individuals receiving health care items or 
     services under such programs activities by race, ethnicity, 
     sex, primary language, and disability status.
       ``(3) Data management.--In collecting data described in 
     paragraph (1), the Secretary, acting through the National 
     Coordinator for Health Information Technology shall--
       ``(A) develop national standards for the management of data 
     collected; and
       ``(B) develop interoperability and security systems for 
     data management.
       ``(b) Data Analysis.--
       ``(1) In general.--For each federally conducted or 
     supported health care or public health program or activity, 
     the Secretary shall analyze data collected under paragraph 
     (a) to detect and monitor trends in health disparities (as 
     defined for purposes of section 485E) at the Federal and 
     State levels.
       ``(c) Data Reporting and Dissemination.--
       ``(1) In general.--The Secretary shall make the analyses 
     described in (b) available to--
       ``(A) the Office of Minority Health;
       ``(B) the National Center on Minority Health and Health 
     Disparities;
       ``(C) the Agency for Healthcare Research and Quality;
       ``(D) the Centers for Disease Control and Prevention;
       ``(E) the Centers for Medicare & Medicaid Services;
       ``(F) the Indian Health Service and epidemiology centers 
     funded under the Indian Health Care Improvement Act;
       ``(G) the Office of Rural health;
       ``(H) other agencies within the Department of Health and 
     Human Services; and
       ``(I) other entities as determined appropriate by the 
     Secretary.
       ``(2) Reporting of data.--The Secretary shall report data 
     and analyses described in (a) and (b) through--
       ``(A) public postings on the Internet websites of the 
     Department of Health and Human Services; and
       ``(B) any other reporting or dissemination mechanisms 
     determined appropriate by the Secretary.
       ``(3) Availability of data.--The Secretary may make data 
     described in (a) and (b) available for additional research, 
     analyses, and dissemination to other Federal agencies, non-
     governmental entities, and the public, in accordance with any 
     Federal agency's data user agreements.
       ``(d) Limitations on Use of Data.--Nothing in this section 
     shall be construed to permit the use of information collected 
     under this section in a manner that would adversely affect 
     any individual.
       ``(e) Protection and Sharing of Data.--
       ``(1) Privacy and other safeguards.--The Secretary shall 
     ensure (through the promulgation of regulations or otherwise) 
     that--
       ``(A) all data collected pursuant to subsection (a) is 
     protected--
       ``(i) under privacy protections that are at least as broad 
     as those that the Secretary applies to other health data 
     under the regulations promulgated under section 264(c) of the 
     Health Insurance Portability and Accountability Act of 1996 
     (Public Law 104-191; 110 Stat. 2033); and
       ``(ii) from all inappropriate internal use by any entity 
     that collects, stores, or receives the data, including use of 
     such data in determinations of eligibility (or continued 
     eligibility) in health plans, and from other inappropriate 
     uses, as defined by the Secretary; and
       ``(B) all appropriate information security safeguards are 
     used in the collection, analysis, and sharing of data 
     collected pursuant to subsection (a).
       ``(2) Data sharing.--The Secretary shall establish 
     procedures for sharing data collected pursuant to subsection 
     (a), measures relating to such data, and analyses of such 
     data, with other relevant Federal and State agencies 
     including the agencies, centers, and entities within the 
     Department of Health and Human Services specified in 
     subsection (c)(1).
       ``(f) Data on Rural Underserved Populations.--The Secretary 
     shall ensure that any data collected in accordance with this 
     section regarding racial and ethnic minority groups are also 
     collected regarding underserved rural and frontier 
     populations.
       ``(g) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of fiscal 
     years 2010 through 2014.
       ``(h) Requirement for Implementation.--Notwithstanding any 
     other provision of this section, data may not be collected 
     under this section unless funds are directly appropriated for 
     such purpose in an appropriations Act.
       ``(i) Consultation.--The Secretary shall consult with the 
     Director of the Office of Personnel Management, the Secretary 
     of Defense, the Secretary of Veterans Affairs, the Director 
     of the Bureau of the Census, the Commissioner of Social 
     Security, and the head of other appropriate Federal agencies 
     in carrying out this section.''.
       (b) Addressing Health Care Disparities in Medicaid and 
     CHIP.--
       (1) Standardized collection requirements included in state 
     plans.--
       (A) Medicaid.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 1396a(a)), as amended by section 2001(d), is 
     amended--
       (i) in paragraph 4), by striking ``and'' at the end;

[[Page 4327]]

       (ii) in paragraph (75), by striking the period at the end 
     and inserting ``; and''; and
       (iii) by inserting after paragraph (75) the following new 
     paragraph:
       ``(76) provide that any data collected under the State plan 
     meets the requirements of section 3101 of the Public Health 
     Service Act.''.
       (B) CHIP.--Section 2108(e) of the Social Security Act (42 
     U.S.C. 1397hh(e)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Data collected and reported in accordance with 
     section 3101 of the Public Health Service Act, with respect 
     to individuals enrolled in the State child health plan (and, 
     in the case of enrollees under 19 years of age, their parents 
     or legal guardians), including data regarding the primary 
     language of such individuals, parents, and legal 
     guardians.''.
       (2) Extending medicare requirement to address health 
     disparities data collection to medicaid and chip.--Title XIX 
     of the Social Security Act (42 U.S.C. 1396 et seq.), as 
     amended by section 2703 is amended by adding at the end the 
     following new section:

     ``SEC. 1946. ADDRESSING HEALTH CARE DISPARITIES.

       ``(a) Evaluating Data Collection Approaches.--The Secretary 
     shall evaluate approaches for the collection of data under 
     this title and title XXI, to be performed in conjunction with 
     existing quality reporting requirements and programs under 
     this title and title XXI, that allow for the ongoing, 
     accurate, and timely collection and evaluation of data on 
     disparities in health care services and performance on the 
     basis of race, ethnicity, sex, primary language, and 
     disability status. In conducting such evaluation, the 
     Secretary shall consider the following objectives:
       ``(1) Protecting patient privacy.
       ``(2) Minimizing the administrative burdens of data 
     collection and reporting on States, providers, and health 
     plans participating under this title or title XXI.
       ``(3) Improving program data under this title and title XXI 
     on race, ethnicity, sex, primary language, and disability 
     status.
       ``(b) Reports to Congress.--
       ``(1) Report on evaluation.--Not later than 18 months after 
     the date of the enactment of this section, the Secretary 
     shall submit to Congress a report on the evaluation conducted 
     under subsection (a). Such report shall, taking into 
     consideration the results of such evaluation--
       ``(A) identify approaches (including defining 
     methodologies) for identifying and collecting and evaluating 
     data on health care disparities on the basis of race, 
     ethnicity, sex, primary language, and disability status for 
     the programs under this title and title XXI; and
       ``(B) include recommendations on the most effective 
     strategies and approaches to reporting HEDIS quality measures 
     as required under section 1852(e)(3) and other nationally 
     recognized quality performance measures, as appropriate, on 
     such bases.
       ``(2) Reports on data analyses.--Not later than 4 years 
     after the date of the enactment of this section, and 4 years 
     thereafter, the Secretary shall submit to Congress a report 
     that includes recommendations for improving the 
     identification of health care disparities for beneficiaries 
     under this title and under title XXI based on analyses of the 
     data collected under subsection (c).
       ``(c) Implementing Effective Approaches.--Not later than 24 
     months after the date of the enactment of this section, the 
     Secretary shall implement the approaches identified in the 
     report submitted under subsection (b)(1) for the ongoing, 
     accurate, and timely collection and evaluation of data on 
     health care disparities on the basis of race, ethnicity, sex, 
     primary language, and disability status.''.

     SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS.

       Title III of the Public Health Service Act (42 U.S.C. 241 
     et seq.), by section 4102, is further amended by adding at 
     the end the following:

               ``PART U--EMPLOYER-BASED WELLNESS PROGRAM

     ``SEC. 399MM. TECHNICAL ASSISTANCE FOR EMPLOYER-BASED 
                   WELLNESS PROGRAMS.

       ``In order to expand the utilization of evidence-based 
     prevention and health promotion approaches in the workplace, 
     the Director shall--
       ``(1) provide employers (including small, medium, and large 
     employers, as determined by the Director) with technical 
     assistance, consultation, tools, and other resources in 
     evaluating such employers' employer-based wellness programs, 
     including--
       ``(A) measuring the participation and methods to increase 
     participation of employees in such programs;
       ``(B) developing standardized measures that assess policy, 
     environmental and systems changes necessary to have a 
     positive health impact on employees' health behaviors, health 
     outcomes, and health care expenditures; and
       ``(C) evaluating such programs as they relate to changes in 
     the health status of employees, the absenteeism of employees, 
     the productivity of employees, the rate of workplace injury, 
     and the medical costs incurred by employees; and
       ``(2) build evaluation capacity among workplace staff by 
     training employers on how to evaluate employer-based wellness 
     programs by ensuring evaluation resources, technical 
     assistance, and consultation are available to workplace staff 
     as needed through such mechanisms as web portals, call 
     centers, or other means.

     ``SEC. 399MM-1. NATIONAL WORKSITE HEALTH POLICIES AND 
                   PROGRAMS STUDY.

       ``(a) In General.--In order to assess, analyze, and monitor 
     over time data about workplace policies and programs, and to 
     develop instruments to assess and evaluate comprehensive 
     workplace chronic disease prevention and health promotion 
     programs, policies and practices, not later than 2 years 
     after the date of enactment of this part, and at regular 
     intervals (to be determined by the Director) thereafter, the 
     Director shall conduct a national worksite health policies 
     and programs survey to assess employer-based health policies 
     and programs.
       ``(b) Report.--Upon the completion of each study under 
     subsection (a), the Director shall submit to Congress a 
     report that includes the recommendations of the Director for 
     the implementation of effective employer-based health 
     policies and programs.

     ``SEC. 399MM-2. PRIORITIZATION OF EVALUATION BY SECRETARY.

       ``The Secretary shall evaluate, in accordance with this 
     part, all programs funded through the Centers for Disease 
     Control and Prevention before conducting such an evaluation 
     of privately funded programs unless an entity with a 
     privately funded wellness program requests such an 
     evaluation.

     ``SEC. 399MM-3. PROHIBITION OF FEDERAL WORKPLACE WELLNESS 
                   REQUIREMENTS.

       ``Notwithstanding any other provision of this part, any 
     recommendations, data, or assessments carried out under this 
     part shall not be used to mandate requirements for workplace 
     wellness programs.''.

     SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.

       Title XXVIII of the Public Health Service Act (42 U.S.C. 
     300hh et seq.) is amended by adding at the end the following:

     ``Subtitle C--Strengthening Public Health Surveillance Systems

     ``SEC. 2821. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS.

       ``(a) In General.--Subject to the availability of 
     appropriations, the Secretary, acting through the Director of 
     the Centers for Disease Control and Prevention, shall 
     establish an Epidemiology and Laboratory Capacity Grant 
     Program to award grants to State health departments as well 
     as local health departments and tribal jurisdictions that 
     meet such criteria as the Director determines appropriate. 
     Academic centers that assist State and eligible local and 
     tribal health departments may also be eligible for funding 
     under this section as the Director determines appropriate. 
     Grants shall be awarded under this section to assist public 
     health agencies in improving surveillance for, and response 
     to, infectious diseases and other conditions of public health 
     importance by--
       ``(1) strengthening epidemiologic capacity to identify and 
     monitor the occurrence of infectious diseases and other 
     conditions of public health importance;
       ``(2) enhancing laboratory practice as well as systems to 
     report test orders and results electronically;
       ``(3) improving information systems including developing 
     and maintaining an information exchange using national 
     guidelines and complying with capacities and functions 
     determined by an advisory council established and appointed 
     by the Director; and
       ``(4) developing and implementing prevention and control 
     strategies.
       ``(b) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section 
     $190,000,000 for each of fiscal years 2010 through 2013, of 
     which--
       ``(1) not less than $95,000,000 shall be made available 
     each such fiscal year for activities under paragraphs (1) and 
     (4) of subsection (a);
       ``(2) not less than $60,000,000 shall be made available 
     each such fiscal year for activities under subsection (a)(3); 
     and
       ``(3) not less than $32,000,000 shall be made available 
     each such fiscal year for activities under subsection 
     (a)(2).''.

     SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE 
                   MANAGEMENT.

       (a) Institute of Medicine Conference on Pain.--
       (1) Convening.--Not later than 1 year after funds are 
     appropriated to carry out this subsection, the Secretary of 
     Health and Human Services shall seek to enter into an 
     agreement with the Institute of Medicine of the National 
     Academies to convene a Conference on Pain (in this subsection 
     referred to as ``the Conference'').
       (2) Purposes.--The purposes of the Conference shall be to--
       (A) increase the recognition of pain as a significant 
     public health problem in the United States;
       (B) evaluate the adequacy of assessment, diagnosis, 
     treatment, and management of acute and chronic pain in the 
     general population, and in identified racial, ethnic, gender, 
     age, and other demographic groups that may be 
     disproportionately affected by inadequacies in the 
     assessment, diagnosis, treatment, and management of pain;
       (C) identify barriers to appropriate pain care;
       (D) establish an agenda for action in both the public and 
     private sectors that will reduce such barriers and 
     significantly improve the state of pain care research, 
     education, and clinical care in the United States.
       (3) Other appropriate entity.--If the Institute of Medicine 
     declines to enter into an agreement under paragraph (1), the 
     Secretary of Health and Human Services may enter into such 
     agreement with another appropriate entity.

[[Page 4328]]

       (4) Report.--A report summarizing the Conference's findings 
     and recommendations shall be submitted to the Congress not 
     later than June 30, 2011.
       (5) Authorization of appropriations.--For the purpose of 
     carrying out this subsection, there is authorized to be 
     appropriated such sums as may be necessary for each of fiscal 
     years 2010 and 2011.
       (b) Pain Research at National Institutes of Health.--Part B 
     of title IV of the Public Health Service Act (42 U.S.C. 284 
     et seq.) is amended by adding at the end the following:

     ``SEC. 409J. PAIN RESEARCH.

       ``(a) Research Initiatives.--
       ``(1) In general.--The Director of NIH is encouraged to 
     continue and expand, through the Pain Consortium, an 
     aggressive program of basic and clinical research on the 
     causes of and potential treatments for pain.
       ``(2) Annual recommendations.--Not less than annually, the 
     Pain Consortium, in consultation with the Division of Program 
     Coordination, Planning, and Strategic Initiatives, shall 
     develop and submit to the Director of NIH recommendations on 
     appropriate pain research initiatives that could be 
     undertaken with funds reserved under section 402A(c)(1) for 
     the Common Fund or otherwise available for such initiatives.
       ``(3) Definition.--In this subsection, the term `Pain 
     Consortium' means the Pain Consortium of the National 
     Institutes of Health or a similar trans-National Institutes 
     of Health coordinating entity designated by the Secretary for 
     purposes of this subsection.
       ``(b) Interagency Pain Research Coordinating Committee.--
       ``(1) Establishment.--The Secretary shall establish not 
     later than 1 year after the date of the enactment of this 
     section and as necessary maintain a committee, to be known as 
     the Interagency Pain Research Coordinating Committee (in this 
     section referred to as the `Committee'), to coordinate all 
     efforts within the Department of Health and Human Services 
     and other Federal agencies that relate to pain research.
       ``(2) Membership.--
       ``(A) In general.--The Committee shall be composed of the 
     following voting members:
       ``(i) Not more than 7 voting Federal representatives 
     appoint by the Secretary from agencies that conduct pain care 
     research and treatment.
       ``(ii) 12 additional voting members appointed under 
     subparagraph (B).
       ``(B) Additional members.--The Committee shall include 
     additional voting members appointed by the Secretary as 
     follows:
       ``(i) 6 non-Federal members shall be appointed from among 
     scientists, physicians, and other health professionals.
       ``(ii) 6 members shall be appointed from members of the 
     general public, who are representatives of leading research, 
     advocacy, and service organizations for individuals with 
     pain-related conditions.
       ``(C) Nonvoting members.--The Committee shall include such 
     nonvoting members as the Secretary determines to be 
     appropriate.
       ``(3) Chairperson.--The voting members of the Committee 
     shall select a chairperson from among such members. The 
     selection of a chairperson shall be subject to the approval 
     of the Director of NIH.
       ``(4) Meetings.--The Committee shall meet at the call of 
     the chairperson of the Committee or upon the request of the 
     Director of NIH, but in no case less often than once each 
     year.
       ``(5) Duties.--The Committee shall--
       ``(A) develop a summary of advances in pain care research 
     supported or conducted by the Federal agencies relevant to 
     the diagnosis, prevention, and treatment of pain and diseases 
     and disorders associated with pain;
       ``(B) identify critical gaps in basic and clinical research 
     on the symptoms and causes of pain;
       ``(C) make recommendations to ensure that the activities of 
     the National Institutes of Health and other Federal agencies 
     are free of unnecessary duplication of effort;
       ``(D) make recommendations on how best to disseminate 
     information on pain care; and
       ``(E) make recommendations on how to expand partnerships 
     between public entities and private entities to expand 
     collaborative, cross-cutting research.
       ``(6) Review.--The Secretary shall review the necessity of 
     the Committee at least once every 2 years.''.
       (c) Pain Care Education and Training.--Part D of title VII 
     of the Public Health Service Act (42 U.S.C. 294 et seq.) is 
     amended by adding at the end the following new section:

     ``SEC. 759. PROGRAM FOR EDUCATION AND TRAINING IN PAIN CARE.

       ``(a) In General.--The Secretary may make awards of grants, 
     cooperative agreements, and contracts to health professions 
     schools, hospices, and other public and private entities for 
     the development and implementation of programs to provide 
     education and training to health care professionals in pain 
     care.
       ``(b) Certain Topics.--An award may be made under 
     subsection (a) only if the applicant for the award agrees 
     that the program carried out with the award will include 
     information and education on--
       ``(1) recognized means for assessing, diagnosing, treating, 
     and managing pain and related signs and symptoms, including 
     the medically appropriate use of controlled substances;
       ``(2) applicable laws, regulations, rules, and policies on 
     controlled substances, including the degree to which 
     misconceptions and concerns regarding such laws, regulations, 
     rules, and policies, or the enforcement thereof, may create 
     barriers to patient access to appropriate and effective pain 
     care;
       ``(3) interdisciplinary approaches to the delivery of pain 
     care, including delivery through specialized centers 
     providing comprehensive pain care treatment expertise;
       ``(4) cultural, linguistic, literacy, geographic, and other 
     barriers to care in underserved populations; and
       ``(5) recent findings, developments, and improvements in 
     the provision of pain care.
       ``(c) Evaluation of Programs.--The Secretary shall 
     (directly or through grants or contracts) provide for the 
     evaluation of programs implemented under subsection (a) in 
     order to determine the effect of such programs on knowledge 
     and practice of pain care.
       ``(d) Pain Care Defined.--For purposes of this section the 
     term `pain care' means the assessment, diagnosis, treatment, 
     or management of acute or chronic pain regardless of 
     causation or body location.
       ``(e) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, such sums as 
     may be necessary for each of the fiscal years 2010 through 
     2012. Amounts appropriated under this subsection shall remain 
     available until expended.''.

     SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION 
                   PROJECT.

       Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 
     1320b-9a(e)(8)) is amended to read as follows:
       ``(8) Appropriation.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to carry out 
     this subsection, $25,000,000 for the period of fiscal years 
     2010 through 2014.''.

                  Subtitle E--Miscellaneous Provisions

     SEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING.

       (a) Finding.--The Senate finds that the costs of prevention 
     programs are difficult to estimate due in part because 
     prevention initiatives are hard to measure and results may 
     occur outside the 5 and 10 year budget windows.
       (b) Sense of Congress.--It is the sense of the Senate that 
     Congress should work with the Congressional Budget Office to 
     develop better methodologies for scoring progress to be made 
     in prevention and wellness programs.

     SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS 
                   INITIATIVES.

       To determine whether existing Federal health and wellness 
     initiatives are effective in achieving their stated goals, 
     the Secretary of Health and Human Services shall--
       (1) conduct an evaluation of such programs as they relate 
     to changes in health status of the American public and 
     specifically on the health status of the Federal workforce, 
     including absenteeism of employees, the productivity of 
     employees, the rate of workplace injury, and the medical 
     costs incurred by employees, and health conditions, including 
     workplace fitness, healthy food and beverages, and incentives 
     in the Federal Employee Health Benefits Program; and
       (2) submit to Congress a report concerning such evaluation, 
     which shall include conclusions concerning the reasons that 
     such existing programs have proven successful or not 
     successful and what factors contributed to such conclusions.

                     TITLE V--HEALTH CARE WORKFORCE

                  Subtitle A--Purpose and Definitions

     SEC. 5001. PURPOSE.

       The purpose of this title is to improve access to and the 
     delivery of health care services for all individuals, 
     particularly low income, underserved, uninsured, minority, 
     health disparity, and rural populations by--
       (1) gathering and assessing comprehensive data in order for 
     the health care workforce to meet the health care needs of 
     individuals, including research on the supply, demand, 
     distribution, diversity, and skills needs of the health care 
     workforce;
       (2) increasing the supply of a qualified health care 
     workforce to improve access to and the delivery of health 
     care services for all individuals;
       (3) enhancing health care workforce education and training 
     to improve access to and the delivery of health care services 
     for all individuals; and
       (4) providing support to the existing health care workforce 
     to improve access to and the delivery of health care services 
     for all individuals.

     SEC. 5002. DEFINITIONS.

       (a) This Title.--In this title:
       (1) Allied health professional.--The term ``allied health 
     professional'' means an allied health professional as defined 
     in section 799B(5) of the Public Heath Service Act (42 U.S.C. 
     295p(5)) who--
       (A) has graduated and received an allied health professions 
     degree or certificate from an institution of higher 
     education; and
       (B) is employed with a Federal, State, local or tribal 
     public health agency, or in a setting where patients might 
     require health care services, including acute care 
     facilities, ambulatory care facilities, personal residences, 
     and other settings located in health professional shortage 
     areas, medically underserved areas, or medically underserved 
     populations, as recognized by the Secretary of Health and 
     Human Services.
       (2) Health care career pathway.--The term ``healthcare 
     career pathway'' means a rigorous, engaging, and high quality 
     set of courses and services that--
       (A) includes an articulated sequence of academic and career 
     courses, including 21st century skills;
       (B) is aligned with the needs of healthcare industries in a 
     region or State;
       (C) prepares students for entry into the full range of 
     postsecondary education options, including registered 
     apprenticeships, and careers;

[[Page 4329]]

       (D) provides academic and career counseling in student-to-
     counselor ratios that allow students to make informed 
     decisions about academic and career options;
       (E) meets State academic standards, State requirements for 
     secondary school graduation and is aligned with requirements 
     for entry into postsecondary education, and applicable 
     industry standards; and
       (F) leads to 2 or more credentials, including--
       (i) a secondary school diploma; and
       (ii) a postsecondary degree, an apprenticeship or other 
     occupational certification, a certificate, or a license.
       (3) Institution of higher education.--The term 
     ``institution of higher education'' has the meaning given the 
     term in sections 101 and 102 of the Higher Education Act of 
     1965 (20 U.S.C. 1001 and 1002).
       (4) Low income individual, state workforce investment 
     board, and local workforce investment board.--
       (A) Low-income individual.--The term ``low-income 
     individual'' has the meaning given that term in section 101 
     of the Workforce investment Act of 1998 (29 U.S.C. 2801).
       (B) State workforce investment board; local workforce 
     investment board.--The terms ``State workforce investment 
     board'' and ``local workforce investment board'', refer to a 
     State workforce investment board established under section 
     111 of the Workforce Investment Act of 1998 (29 U.S.C. 2821) 
     and a local workforce investment board established under 
     section 117 of such Act (29 U.S.C. 2832), respectively.
       (5) Postsecondary education.--The term ``postsecondary 
     education'' means--
       (A) a 4-year program of instruction, or not less than a 1-
     year program of instruction that is acceptable for credit 
     toward an associate or a baccalaureate degree, offered by an 
     institution of higher education; or
       (B) a certificate or registered apprenticeship program at 
     the postsecondary level offered by an institution of higher 
     education or a non-profit educational institution.
       (6) Registered apprenticeship program.--The term 
     ``registered apprenticeship program'' means an industry 
     skills training program at the postsecondary level that 
     combines technical and theoretical training through structure 
     on the job learning with related instruction (in a classroom 
     or through distance learning) while an individual is 
     employed, working under the direction of qualified personnel 
     or a mentor, and earning incremental wage increases aligned 
     to enhance job proficiency, resulting in the acquisition of a 
     nationally recognized and portable certificate, under a plan 
     approved by the Office of Apprenticeship or a State agency 
     recognized by the Department of Labor.
       (b) Title VII of the Public Health Service Act.--Section 
     799B of the Public Health Service Act (42 U.S.C. 295p) is 
     amended--
       (1) by striking paragraph (3) and inserting the following:
       ``(3) Physician assistant education program.--The term 
     `physician assistant education program' means an educational 
     program in a public or private institution in a State that--
       ``(A) has as its objective the education of individuals 
     who, upon completion of their studies in the program, be 
     qualified to provide primary care medical services with the 
     supervision of a physician; and
       ``(B) is accredited by the Accreditation Review Commission 
     on Education for the Physician Assistant.''; and
       (2) by adding at the end the following:
       ``(12) Area health education center.--The term `area health 
     education center' means a public or nonprofit private 
     organization that has a cooperative agreement or contract in 
     effect with an entity that has received an award under 
     subsection (a)(1) or (a)(2) of section 751, satisfies the 
     requirements in section 751(d)(1), and has as one of its 
     principal functions the operation of an area health education 
     center. Appropriate organizations may include hospitals, 
     health organizations with accredited primary care training 
     programs, accredited physician assistant educational programs 
     associated with a college or university, and universities or 
     colleges not operating a school of medicine or osteopathic 
     medicine.
       ``(13) Area health education center program.--The term 
     `area health education center program' means cooperative 
     program consisting of an entity that has received an award 
     under subsection (a)(1) or (a)(2) of section 751 for the 
     purpose of planning, developing, operating, and evaluating an 
     area health education center program and one or more area 
     health education centers, which carries out the required 
     activities described in section 751(c), satisfies the program 
     requirements in such section, has as one of its principal 
     functions identifying and implementing strategies and 
     activities that address health care workforce needs in its 
     service area, in coordination with the local workforce 
     investment boards.
       ``(14) Clinical social worker.--The term `clinical social 
     worker' has the meaning given the term in section 1861(hh)(1) 
     of the Social Security Act (42 U.S.C. 1395x(hh)(1)).
       ``(15) Cultural competency.--The term `cultural competency' 
     shall be defined by the Secretary in a manner consistent with 
     section 1707(d)(3).
       ``(16) Direct care worker.--The term `direct care worker' 
     has the meaning given that term in the 2010 Standard 
     Occupational Classifications of the Department of Labor for 
     Home Health Aides [31-1011], Psychiatric Aides [31-1013], 
     Nursing Assistants [31-1014], and Personal Care Aides [39-
     9021].
       ``(17) Federally qualified health center.--The term 
     `Federally qualified health center' has the meaning given 
     that term in section 1861(aa) of the Social Security Act (42 
     U.S.C. 1395x(aa)).
       ``(18) Frontier health professional shortage area.--The 
     term `frontier health professional shortage area' means an 
     area--
       ``(A) with a population density less than 6 persons per 
     square mile within the service area; and
       ``(B) with respect to which the distance or time for the 
     population to access care is excessive.
       ``(19) Graduate psychology.--The term `graduate psychology' 
     means an accredited program in professional psychology.
       ``(20) Health disparity population.--The term `health 
     disparity population' has the meaning given such term in 
     section 903(d)(1).
       ``(21) Health literacy.--The term `health literacy' means 
     the degree to which an individual has the capacity to obtain, 
     communicate, process, and understand health information and 
     services in order to make appropriate health decisions.
       ``(22) Mental health service professional.--The term 
     `mental health service professional' means an individual with 
     a graduate or postgraduate degree from an accredited 
     institution of higher education in psychiatry, psychology, 
     school psychology, behavioral pediatrics, psychiatric 
     nursing, social work, school social work, substance abuse 
     disorder prevention and treatment, marriage and family 
     counseling, school counseling, or professional counseling.
       ``(23) One-stop delivery system center.--The term `one-stop 
     delivery system' means a one-stop delivery system described 
     in section 134(c) of the Workforce Investment Act of 1998 (29 
     U.S.C. 2864(c)).
       ``(24) Paraprofessional child and adolescent mental health 
     worker.--The term `paraprofessional child and adolescent 
     mental health worker' means an individual who is not a mental 
     or behavioral health service professional, but who works at 
     the first stage of contact with children and families who are 
     seeking mental or behavioral health services, including 
     substance abuse prevention and treatment services.
       ``(25) Racial and ethnic minority group; racial and ethnic 
     minority population.--The terms `racial and ethnic minority 
     group' and `racial and ethnic minority population' have the 
     meaning given the term `racial and ethnic minority group' in 
     section 1707.
       ``(26) Rural health clinic.--The term `rural health clinic' 
     has the meaning given that term in section 1861(aa) of the 
     Social Security Act (42 U.S.C. 1395x(aa)).''.
       (c) Title VIII of the Public Health Service Act.--Section 
     801 of the Public Health Service Act (42 U.S.C. 296) is 
     amended--
       (1) in paragraph (2)--
       (A) by striking ``means a'' and inserting ``means an 
     accredited (as defined in paragraph 6)''; and
       (B) by striking the period as inserting the following: 
     ``where graduates are--
       ``(A) authorized to sit for the National Council Licensure 
     EXamination-Registered Nurse (NCLEX-RN); or
       ``(B) licensed registered nurses who will receive a 
     graduate or equivalent degree or training to become an 
     advanced education nurse as defined by section 811(b).''; and
       (2) by adding at the end the following:
       ``(16) Accelerated nursing degree program.--The term 
     `accelerated nursing degree program' means a program of 
     education in professional nursing offered by an accredited 
     school of nursing in which an individual holding a bachelors 
     degree in another discipline receives a BSN or MSN degree in 
     an accelerated time frame as determined by the accredited 
     school of nursing.
       ``(17) Bridge or degree completion program.--The term 
     `bridge or degree completion program' means a program of 
     education in professional nursing offered by an accredited 
     school of nursing, as defined in paragraph (2), that leads to 
     a baccalaureate degree in nursing. Such programs may include, 
     Registered Nurse (RN) to Bachelor's of Science of Nursing 
     (BSN) programs, RN to MSN (Master of Science of Nursing) 
     programs, or BSN to Doctoral programs.''.

          Subtitle B--Innovations in the Health Care Workforce

     SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION.

       (a) Purpose.--It is the purpose of this section to 
     establish a National Health Care Workforce Commission that--
       (1) serves as a national resource for Congress, the 
     President, States, and localities;
       (2) communicates and coordinates with the Departments of 
     Health and Human Services, Labor, Veterans Affairs, Homeland 
     Security, and Education on related activities administered by 
     one or more of such Departments;
       (3) develops and commissions evaluations of education and 
     training activities to determine whether the demand for 
     health care workers is being met;
       (4) identifies barriers to improved coordination at the 
     Federal, State, and local levels and recommend ways to 
     address such barriers; and
       (5) encourages innovations to address population needs, 
     constant changes in technology, and other environmental 
     factors.
       (b) Establishment.--There is hereby established the 
     National Health Care Workforce Commission (in this section 
     referred to as the ``Commission'').
       (c) Membership.--

[[Page 4330]]

       (1) Number and appointment.--The Commission shall be 
     composed of 15 members to be appointed by the Comptroller 
     General, without regard to section 5 of the Federal Advisory 
     Committee Act (5 U.S.C. App.).
       (2) Qualifications.--
       (A) In general.--The membership of the Commission shall 
     include individuals--
       (i) with national recognition for their expertise in health 
     care labor market analysis, including health care workforce 
     analysis; health care finance and economics; health care 
     facility management; health care plans and integrated 
     delivery systems; health care workforce education and 
     training; health care philanthropy; providers of health care 
     services; and other related fields; and
       (ii) who will provide a combination of professional 
     perspectives, broad geographic representation, and a balance 
     between urban, suburban, rural, and frontier representatives.
       (B) Inclusion.--
       (i) In general.--The membership of the Commission shall 
     include no less than one representative of--

       (I) the health care workforce and health professionals;
       (II) employers;
       (III) third-party payers;
       (IV) individuals skilled in the conduct and interpretation 
     of health care services and health economics research;
       (V) representatives of consumers;
       (VI) labor unions;
       (VII) State or local workforce investment boards; and
       (VIII) educational institutions (which may include 
     elementary and secondary institutions, institutions of higher 
     education, including 2 and 4 year institutions, or registered 
     apprenticeship programs).

       (ii) Additional members.--The remaining membership may 
     include additional representatives from clause (i) and other 
     individuals as determined appropriate by the Comptroller 
     General of the United States.
       (C) Majority non-providers.--Individuals who are directly 
     involved in health professions education or practice shall 
     not constitute a majority of the membership of the 
     Commission.
       (D) Ethical disclosure.--The Comptroller General shall 
     establish a system for public disclosure by members of the 
     Commission of financial and other potential conflicts of 
     interest relating to such members. Members of the Commission 
     shall be treated as employees of Congress for purposes of 
     applying title I of the Ethics in Government Act of 1978. 
     Members of the Commission shall not be treated as special 
     government employees under title 18, United States Code.
       (3) Terms.--
       (A) In general.--The terms of members of the Commission 
     shall be for 3 years except that the Comptroller General 
     shall designate staggered terms for the members first 
     appointed.
       (B) Vacancies.--Any member appointed to fill a vacancy 
     occurring before the expiration of the term for which the 
     member's predecessor was appointed shall be appointed only 
     for the remainder of that term. A member may serve after the 
     expiration of that member's term until a successor has taken 
     office. A vacancy in the Commission shall be filled in the 
     manner in which the original appointment was made.
       (C) Initial appointments.--The Comptroller General shall 
     make initial appointments of members to the Commission not 
     later than September 30, 2010.
       (4) Compensation.--While serving on the business of the 
     Commission (including travel time), a member of the 
     Commission shall be entitled to compensation at the per diem 
     equivalent of the rate provided for level IV of the Executive 
     Schedule under section 5315 of tile 5, United States Code, 
     and while so serving away from home and the member's regular 
     place of business, a member may be allowed travel expenses, 
     as authorized by the Chairman of the Commission. Physicians 
     serving as personnel of the Commission may be provided a 
     physician comparability allowance by the Commission in the 
     same manner as Government physicians may be provided such an 
     allowance by an agency under section 5948 of title 5, United 
     States Code, and for such purpose subsection (i) of such 
     section shall apply to the Commission in the same manner as 
     it applies to the Tennessee Valley Authority. For purposes of 
     pay (other than pay of members of the Commission) and 
     employment benefits, rights, and privileges, all personnel of 
     the Commission shall be treated as if they were employees of 
     the United States Senate. Personnel of the Commission shall 
     not be treated as employees of the Government Accountability 
     Office for any purpose.
       (5) Chairman, vice chairman.--The Comptroller General shall 
     designate a member of the Commission, at the time of 
     appointment of the member, as Chairman and a member as Vice 
     Chairman for that term of appointment, except that in the 
     case of vacancy of the chairmanship or vice chairmanship, the 
     Comptroller General may designate another member for the 
     remainder of that member's term.
       (6) Meetings.--The Commission shall meet at the call of the 
     chairman, but no less frequently than on a quarterly basis.
       (d) Duties.--
       (1) Recognition, dissemination, and communication.--The 
     Commission shall--
       (A) recognize efforts of Federal, State, and local 
     partnerships to develop and offer health care career pathways 
     of proven effectiveness;
       (B) disseminate information on promising retention 
     practices for health care professionals; and
       (C) communicate information on important policies and 
     practices that affect the recruitment, education and 
     training, and retention of the health care workforce.
       (2) Review of health care workforce and annual reports.--In 
     order to develop a fiscally sustainable integrated workforce 
     that supports a high-quality, readily accessible health care 
     delivery system that meets the needs of patients and 
     populations, the Commission, in consultation with relevant 
     Federal, State, and local agencies, shall--
       (A) review current and projected health care workforce 
     supply and demand, including the topics described in 
     paragraph (3);
       (B) make recommendations to Congress and the Administration 
     concerning national health care workforce priorities, goals, 
     and policies;
       (C) by not later than October 1 of each year (beginning 
     with 2011), submit a report to Congress and the 
     Administration containing the results of such reviews and 
     recommendations concerning related policies; and
       (D) by not later than April 1 of each year (beginning with 
     2011), submit a report to Congress and the Administration 
     containing a review of, and recommendations on, at a minimum 
     one high priority area as described in paragraph (4).
       (3) Specific topics to be reviewed.--The topics described 
     in this paragraph include--
       (A) current health care workforce supply and distribution, 
     including demographics, skill sets, and demands, with 
     projected demands during the subsequent 10 and 25 year 
     periods;
       (B) health care workforce education and training capacity, 
     including the number of students who have completed education 
     and training, including registered apprenticeships; the 
     number of qualified faculty; the education and training 
     infrastructure; and the education and training demands, with 
     projected demands during the subsequent 10 and 25 year 
     periods;
       (C) the education loan and grant programs in titles VII and 
     VIII of the Public Health Service Act (42 U.S.C. 292 et seq. 
     and 296 et seq.), with recommendations on whether such 
     programs should become part of the Higher Education Act of 
     1965 (20 U.S.C. 1001 et seq);
       (D) the implications of new and existing Federal policies 
     which affect the health care workforce, including Medicare 
     and Medicaid graduate medical education policies, titles VII 
     and VIII of the Public Health Service Act (42 U.S.C. 292 et 
     seq. and 296 et seq.), the National Health Service Corps 
     (with recommendations for aligning such programs with 
     national health workforce priorities and goals), and other 
     health care workforce programs, including those supported 
     through the Workforce Investment Act of 1998 (29 U.S.C. 2801 
     et seq.), the Carl D. Perkins Career and Technical Education 
     Act of 2006 (20 U.S.C. 2301 et seq.), the Higher Education 
     Act of 1965 (20 U.S.C. 1001 et seq.), and any other Federal 
     health care workforce programs;
       (E) the health care workforce needs of special populations, 
     such as minorities, rural populations, medically underserved 
     populations, gender specific needs, individuals with 
     disabilities, and geriatric and pediatric populations with 
     recommendations for new and existing Federal policies to meet 
     the needs of these special populations; and
       (F) recommendations creating or revising national loan 
     repayment programs and scholarship programs to require low-
     income, minority medical students to serve in their home 
     communities, if designated as medical underserved community.
       (4) High priority areas.--
       (A) In general.--The initial high priority topics described 
     in this paragraph include each of the following:
       (i) Integrated health care workforce planning that 
     identifies health care professional skills needed and 
     maximizes the skill sets of health care professionals across 
     disciplines.
       (ii) An analysis of the nature, scopes of practice, and 
     demands for health care workers in the enhanced information 
     technology and management workplace.
       (iii) An analysis of how to align Medicare and Medicaid 
     graduate medical education policies with national workforce 
     goals.
       (iv) The education and training capacity, projected 
     demands, and integration with the health care delivery system 
     of each of the following:

       (I) Nursing workforce capacity at all levels.
       (II) Oral health care workforce capacity at all levels.
       (III) Mental and behavioral health care workforce capacity 
     at all levels.
       (IV) Allied health and public health care workforce 
     capacity at all levels.
       (V) Emergency medical service workforce capacity, including 
     the retention and recruitment of the volunteer workforce, at 
     all levels.
       (VI) The geographic distribution of health care providers 
     as compared to the identified health care workforce needs of 
     States and regions.

       (B) Future determinations.--The Commission may require that 
     additional topics be included under subparagraph (A). The 
     appropriate committees of Congress may recommend to the 
     Commission the inclusion of other topics for health care 
     workforce development areas that require special attention.
       (5) Grant program.--The Commission shall--
       (A) review implementation progress reports on, and report 
     to Congress about, the State Health Care Workforce 
     Development Grant program established in section 5102;
       (B) in collaboration with the Department of Labor and in 
     coordination with the Department of Education and other 
     relevant Federal agencies, make recommendations to the fiscal 
     and

[[Page 4331]]

     administrative agent under section 5102(b) for grant 
     recipients under section 5102;
       (C) assess the implementation of the grants under such 
     section; and
       (D) collect performance and report information, including 
     identified models and best practices, on grants from the 
     fiscal and administrative agent under such section and 
     distribute this information to Congress, relevant Federal 
     agencies, and to the public.
       (6) Study.--The Commission shall study effective mechanisms 
     for financing education and training for careers in health 
     care, including public health and allied health.
       (7) Recommendations.--The Commission shall submit 
     recommendations to Congress, the Department of Labor, and the 
     Department of Health and Human Services about improving 
     safety, health, and worker protections in the workplace for 
     the health care workforce.
       (8) Assessment.--The Commission shall assess and receive 
     reports from the National Center for Health Care Workforce 
     Analysis established under section 761(b) of the Public 
     Service Health Act (as amended by section 5103).
       (e) Consultation With Federal, State, and Local Agencies, 
     Congress, and Other Organizations.--
       (1) In general.--The Commission shall consult with Federal 
     agencies (including the Departments of Health and Human 
     Services, Labor, Education, Commerce, Agriculture, Defense, 
     and Veterans Affairs and the Environmental Protection 
     Agency), Congress, the Medicare Payment Advisory Commission, 
     the Medicaid and CHIP Payment and Access Commission, and, to 
     the extent practicable, with State and local agencies, Indian 
     tribes, voluntary health care organizations, professional 
     societies, and other relevant public-private health care 
     partnerships.
       (2) Obtaining official data.--The Commission, consistent 
     with established privacy rules, may secure directly from any 
     department or agency of the Executive Branch information 
     necessary to enable the Commission to carry out this section.
       (3) Detail of federal government employees.--An employee of 
     the Federal Government may be detailed to the Commission 
     without reimbursement. The detail of such an employee shall 
     be without interruption or loss of civil service status.
       (f) Director and Staff; Experts and Consultants.--Subject 
     to such review as the Comptroller General of the United 
     States determines to be necessary to ensure the efficient 
     administration of the Commission, the Commission may--
       (1) employ and fix the compensation of an executive 
     director that shall not exceed the rate of basic pay payable 
     for level V of the Executive Schedule and such other 
     personnel as may be necessary to carry out its duties 
     (without regard to the provisions of title 5, United States 
     Code, governing appointments in the competitive service);
       (2) seek such assistance and support as may be required in 
     the performance of its duties from appropriate Federal 
     departments and agencies;
       (3) enter into contracts or make other arrangements, as may 
     be necessary for the conduct of the work of the Commission 
     (without regard to section 3709 of the Revised Statutes (41 
     U.S.C. 5));
       (4) make advance, progress, and other payments which relate 
     to the work of the Commission;
       (5) provide transportation and subsistence for persons 
     serving without compensation; and
       (6) prescribe such rules and regulations as the Commission 
     determines to be necessary with respect to the internal 
     organization and operation of the Commission.
       (g) Powers.--
       (1) Data collection.--In order to carry out its functions 
     under this section, the Commission shall--
       (A) utilize existing information, both published and 
     unpublished, where possible, collected and assessed either by 
     its own staff or under other arrangements made in accordance 
     with this section, including coordination with the Bureau of 
     Labor Statistics;
       (B) carry out, or award grants or contracts for the 
     carrying out of, original research and development, where 
     existing information is inadequate, and
       (C) adopt procedures allowing interested parties to submit 
     information for the Commission's use in making reports and 
     recommendations.
       (2) Access of the government accountability office to 
     information.--The Comptroller General of the United States 
     shall have unrestricted access to all deliberations, records, 
     and data of the Commission, immediately upon request.
       (3) Periodic audit.--The Commission shall be subject to 
     periodic audit by an independent public accountant under 
     contract to the Commission.
       (h) Authorization of Appropriations.--
       (1) Request for appropriations.--The Commission shall 
     submit requests for appropriations in the same manner as the 
     Comptroller General of the United States submits requests for 
     appropriations. Amounts so appropriated for the Commission 
     shall be separate from amounts appropriated for the 
     Comptroller General.
       (2) Authorization.--There are authorized to be appropriated 
     such sums as may be necessary to carry out this section.
       (3) Gifts and services.--The Commission may not accept 
     gifts, bequeaths, or donations of property, but may accept 
     and use donations of services for purposes of carrying out 
     this section.
       (i) Definitions.--In this section:
       (1) Health care workforce.--The term ``health care 
     workforce'' includes all health care providers with direct 
     patient care and support responsibilities, such as 
     physicians, nurses, nurse practitioners, primary care 
     providers, preventive medicine physicians, optometrists, 
     ophthalmologists, physician assistants, pharmacists, 
     dentists, dental hygienists, and other oral healthcare 
     professionals, allied health professionals, doctors of 
     chiropractic, community health workers, health care 
     paraprofessionals, direct care workers, psychologists and 
     other behavioral and mental health professionals (including 
     substance abuse prevention and treatment providers), social 
     workers, physical and occupational therapists, certified 
     nurse midwives, podiatrists, the EMS workforce (including 
     professional and volunteer ambulance personnel and 
     firefighters who perform emergency medical services), 
     licensed complementary and alternative medicine providers, 
     integrative health practitioners, public health 
     professionals, and any other health professional that the 
     Comptroller General of the United States determines 
     appropriate.
       (2) Health professionals.--The term ``health 
     professionals'' includes--
       (A) dentists, dental hygienists, primary care providers, 
     specialty physicians, nurses, nurse practitioners, physician 
     assistants, psychologists and other behavioral and mental 
     health professionals (including substance abuse prevention 
     and treatment providers), social workers, physical and 
     occupational therapists, public health professionals, 
     clinical pharmacists, allied health professionals, doctors of 
     chiropractic, community health workers, school nurses, 
     certified nurse midwives, podiatrists, licensed complementary 
     and alternative medicine providers, the EMS workforce 
     (including professional and volunteer ambulance personnel and 
     firefighters who perform emergency medical services), and 
     integrative health practitioners;
       (B) national representatives of health professionals;
       (C) representatives of schools of medicine, osteopathy, 
     nursing, dentistry, optometry, pharmacy, chiropractic, allied 
     health, educational programs for public health professionals, 
     behavioral and mental health professionals (as so defined), 
     social workers, pharmacists, physical and occupational 
     therapists, oral health care industry dentistry and dental 
     hygiene, and physician assistants;
       (D) representatives of public and private teaching 
     hospitals, and ambulatory health facilities, including 
     Federal medical facilities; and
       (E) any other health professional the Comptroller General 
     of the United States determines appropriate.

     SEC. 5102. STATE HEALTH CARE WORKFORCE DEVELOPMENT GRANTS.

       (a) Establishment.--There is established a competitive 
     health care workforce development grant program (referred to 
     in this section as the ``program'') for the purpose of 
     enabling State partnerships to complete comprehensive 
     planning and to carry out activities leading to coherent and 
     comprehensive health care workforce development strategies at 
     the State and local levels.
       (b) Fiscal and Administrative Agent.--The Health Resources 
     and Services Administration of the Department of Health and 
     Human Services (referred to in this section as the 
     ``Administration'') shall be the fiscal and administrative 
     agent for the grants awarded under this section. The 
     Administration is authorized to carry out the program, in 
     consultation with the National Health Care Workforce 
     Commission (referred to in this section as the 
     ``Commission''), which shall review reports on the 
     development, implementation, and evaluation activities of the 
     grant program, including--
       (1) administering the grants;
       (2) providing technical assistance to grantees; and
       (3) reporting performance information to the Commission.
       (c) Planning Grants.--
       (1) Amount and duration.--A planning grant shall be awarded 
     under this subsection for a period of not more than one year 
     and the maximum award may not be more than $150,000.
       (2) Eligibility.--To be eligible to receive a planning 
     grant, an entity shall be an eligible partnership. An 
     eligible partnership shall be a State workforce investment 
     board, if it includes or modifies the members to include at 
     least one representative from each of the following: health 
     care employer, labor organization, a public 2-year 
     institution of higher education, a public 4-year institution 
     of higher education, the recognized State federation of 
     labor, the State public secondary education agency, the State 
     P-16 or P-20 Council if such a council exists, and a 
     philanthropic organization that is actively engaged in 
     providing learning, mentoring, and work opportunities to 
     recruit, educate, and train individuals for, and retain 
     individuals in, careers in health care and related 
     industries.
       (3) Fiscal and administrative agent.--The Governor of the 
     State receiving a planning grant has the authority to appoint 
     a fiscal and an administrative agency for the partnership.
       (4) Application.--Each State partnership desiring a 
     planning grant shall submit an application to the 
     Administrator of the Administration at such time and in such 
     manner, and accompanied by such information as the 
     Administrator may reasonable require. Each application 
     submitted for a planning grant shall describe the members of 
     the State partnership, the activities for which assistance is 
     sought, the proposed

[[Page 4332]]

     performance benchmarks to be used to measure progress under 
     the planning grant, a budget for use of the funds to complete 
     the required activities described in paragraph (5), and such 
     additional assurance and information as the Administrator 
     determines to be essential to ensure compliance with the 
     grant program requirements.
       (5) Required activities.--A State partnership receiving a 
     planning grant shall carry out the following:
       (A) Analyze State labor market information in order to 
     create health care career pathways for students and adults, 
     including dislocated workers.
       (B) Identify current and projected high demand State or 
     regional health care sectors for purposes of planning career 
     pathways.
       (C) Identify existing Federal, State, and private resources 
     to recruit, educate or train, and retain a skilled health 
     care workforce and strengthen partnerships.
       (D) Describe the academic and health care industry skill 
     standards for high school graduation, for entry into 
     postsecondary education, and for various credentials and 
     licensure.
       (E) Describe State secondary and postsecondary education 
     and training policies, models, or practices for the health 
     care sector, including career information and guidance 
     counseling.
       (F) Identify Federal or State policies or rules to 
     developing a coherent and comprehensive health care workforce 
     development strategy and barriers and a plan to resolve these 
     barriers.
       (G) Participate in the Administration's evaluation and 
     reporting activities.
       (6) Performance and evaluation.--Before the State 
     partnership receives a planning grant, such partnership and 
     the Administrator of the Administration shall jointly 
     determine the performance benchmarks that will be established 
     for the purposes of the planning grant.
       (7) Match.--Each State partnership receiving a planning 
     grant shall provide an amount, in cash or in kind, that is 
     not less that 15 percent of the amount of the grant, to carry 
     out the activities supported by the grant. The matching 
     requirement may be provided from funds available under other 
     Federal, State, local or private sources to carry out the 
     activities.
       (8) Report.--
       (A) Report to administration.--Not later than 1 year after 
     a State partnership receives a planning grant, the 
     partnership shall submit a report to the Administration on 
     the State's performance of the activities under the grant, 
     including the use of funds, including matching funds, to 
     carry out required activities, and a description of the 
     progress of the State workforce investment board in meeting 
     the performance benchmarks.
       (B) Report to congress.--The Administration shall submit a 
     report to Congress analyzing the planning activities, 
     performance, and fund utilization of each State grant 
     recipient, including an identification of promising practices 
     and a profile of the activities of each State grant 
     recipient.
       (d) Implementation Grants.--
       (1) In general.--The Administration shall--
       (A) competitively award implementation grants to State 
     partnerships to enable such partnerships to implement 
     activities that will result in a coherent and comprehensive 
     plan for health workforce development that will address 
     current and projected workforce demands within the State; and
       (B) inform the Commission and Congress about the awards 
     made.
       (2) Duration.--An implementation grant shall be awarded for 
     a period of no more than 2 years, except in those cases where 
     the Administration determines that the grantee is high 
     performing and the activities supported by the grant warrant 
     up to 1 additional year of funding.
       (3) Eligibility.--To be eligible for an implementation 
     grant, a State partnership shall have--
       (A) received a planning grant under subsection (c) and 
     completed all requirements of such grant; or
       (B) completed a satisfactory application, including a plan 
     to coordinate with required partners and complete the 
     required activities during the 2 year period of the 
     implementation grant.
       (4) Fiscal and administrative agent.--A State partnership 
     receiving an implementation grant shall appoint a fiscal and 
     an administration agent for the implementation of such grant.
       (5) Application.--Each eligible State partnership desiring 
     an implementation grant shall submit an application to the 
     Administration at such time, in such manner, and accompanied 
     by such information as the Administration may reasonably 
     require. Each application submitted shall include--
       (A) a description of the members of the State partnership;
       (B) a description of how the State partnership completed 
     the required activities under the planning grant, if 
     applicable;
       (C) a description of the activities for which 
     implementation grant funds are sought, including grants to 
     regions by the State partnership to advance coherent and 
     comprehensive regional health care workforce planning 
     activities;
       (D) a description of how the State partnership will 
     coordinate with required partners and complete the required 
     partnership activities during the duration of an 
     implementation grant;
       (E) a budget proposal of the cost of the activities 
     supported by the implementation grant and a timeline for the 
     provision of matching funds required;
       (F) proposed performance benchmarks to be used to assess 
     and evaluate the progress of the partnership activities;
       (G) a description of how the State partnership will collect 
     data to report progress in grant activities; and
       (H) such additional assurances as the Administration 
     determines to be essential to ensure compliance with grant 
     requirements.
       (6) Required activities.--
       (A) In general.--A State partnership that receives an 
     implementation grant may reserve not less than 60 percent of 
     the grant funds to make grants to be competitively awarded by 
     the State partnership, consistent with State procurement 
     rules, to encourage regional partnerships to address health 
     care workforce development needs and to promote innovative 
     health care workforce career pathway activities, including 
     career counseling, learning, and employment.
       (B) Eligible partnership duties.--An eligible State 
     partnership receiving an implementation grant shall--
       (i) identify and convene regional leadership to discuss 
     opportunities to engage in statewide health care workforce 
     development planning, including the potential use of 
     competitive grants to improve the development, distribution, 
     and diversity of the regional health care workforce; the 
     alignment of curricula for health care careers; and the 
     access to quality career information and guidance and 
     education and training opportunities;
       (ii) in consultation with key stakeholders and regional 
     leaders, take appropriate steps to reduce Federal, State, or 
     local barriers to a comprehensive and coherent strategy, 
     including changes in State or local policies to foster 
     coherent and comprehensive health care workforce development 
     activities, including health care career pathways at the 
     regional and State levels, career planning information, 
     retraining for dislocated workers, and as appropriate, 
     requests for Federal program or administrative waivers;
       (iii) develop, disseminate, and review with key 
     stakeholders a preliminary statewide strategy that addresses 
     short- and long-term health care workforce development supply 
     versus demand;
       (iv) convene State partnership members on a regular basis, 
     and at least on a semiannual basis;
       (v) assist leaders at the regional level to form 
     partnerships, including technical assistance and capacity 
     building activities;
       (vi) collect and assess data on and report on the 
     performance benchmarks selected by the State partnership and 
     the Administration for implementation activities carried out 
     by regional and State partnerships; and
       (vii) participate in the Administration's evaluation and 
     reporting activities.
       (7) Performance and evaluation.--Before the State 
     partnership receives an implementation grant, it and the 
     Administrator shall jointly determine the performance 
     benchmarks that shall be established for the purposes of the 
     implementation grant.
       (8) Match.--Each State partnership receiving an 
     implementation grant shall provide an amount, in cash or in 
     kind that is not less than 25 percent of the amount of the 
     grant, to carry out the activities supported by the grant. 
     The matching funds may be provided from funds available from 
     other Federal, State, local, or private sources to carry out 
     such activities.
       (9) Reports.--
       (A) Report to administration.--For each year of the 
     implementation grant, the State partnership receiving the 
     implementation grant shall submit a report to the 
     Administration on the performance of the State of the grant 
     activities, including a description of the use of the funds, 
     including matched funds, to complete activities, and a 
     description of the performance of the State partnership in 
     meeting the performance benchmarks.
       (B) Report to congress.--The Administration shall submit a 
     report to Congress analyzing implementation activities, 
     performance, and fund utilization of the State grantees, 
     including an identification of promising practices and a 
     profile of the activities of each State grantee.
       (e) Authorization for Appropriations.--
       (1) Planning grants.--There are authorized to be 
     appropriated to award planning grants under subsection (c) 
     $8,000,000 for fiscal year 2010, and such sums as may be 
     necessary for each subsequent fiscal year.
       (2) Implementation grants.--There are authorized to be 
     appropriated to award implementation grants under subsection 
     (d), $150,000,000 for fiscal year 2010, and such sums as may 
     be necessary for each subsequent fiscal year.

     SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT.

       (a) In General.--Section 761 of the Public Health Service 
     Act (42 U.S.C. 294m) is amended--
       (1) by redesignating subsection (c) as subsection (e);
       (2) by striking subsection (b) and inserting the following:
       ``(b) National Center for Health Care Workforce Analysis.--
       ``(1) Establishment.--The Secretary shall establish the 
     National Center for Health Workforce Analysis (referred to in 
     this section as the `National Center').
       ``(2) Purposes.--The National Center, in coordination to 
     the extent practicable with the National Health Care 
     Workforce Commission (established in section 5101 of the 
     Patient Protection and Affordable Care Act), and relevant 
     regional and State centers and agencies, shall--
       ``(A) provide for the development of information describing 
     and analyzing the health care workforce and workforce related 
     issues;
       ``(B) carry out the activities under section 792(a);
       ``(C) annually evaluate programs under this title;

[[Page 4333]]

       ``(D) develop and publish performance measures and 
     benchmarks for programs under this title; and
       ``(E) establish, maintain, and publicize a national 
     Internet registry of each grant awarded under this title and 
     a database to collect data from longitudinal evaluations (as 
     described in subsection (d)(2)) on performance measures (as 
     developed under sections 749(d)(3), 757(d)(3), and 
     762(a)(3)).
       ``(3) Collaboration and data sharing.--
       ``(A) In general.--The National Center shall collaborate 
     with Federal agencies and relevant professional and 
     educational organizations or societies for the purpose of 
     linking data regarding grants awarded under this title.
       ``(B) Contracts for health workforce analysis.--For the 
     purpose of carrying out the activities described in 
     subparagraph (A), the National Center may enter into 
     contracts with relevant professional and educational 
     organizations or societies.
       ``(c) State and Regional Centers for Health Workforce 
     Analysis.--
       ``(1) In general.--The Secretary shall award grants to, or 
     enter into contracts with, eligible entities for purposes 
     of--
       ``(A) collecting, analyzing, and reporting data regarding 
     programs under this title to the National Center and to the 
     public; and
       ``(B) providing technical assistance to local and regional 
     entities on the collection, analysis, and reporting of data.
       ``(2) Eligible entities.--To be eligible for a grant or 
     contract under this subsection, an entity shall--
       ``(A) be a State, a State workforce investment board, a 
     public health or health professions school, an academic 
     health center, or an appropriate public or private nonprofit 
     entity; and
       ``(B) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(d) Increase in Grants for Longitudinal Evaluations.--
       ``(1) In general.--The Secretary shall increase the amount 
     awarded to an eligible entity under this title for a 
     longitudinal evaluation of individuals who have received 
     education, training, or financial assistance from programs 
     under this title.
       ``(2) Capability.--A longitudinal evaluation shall be 
     capable of--
       ``(A) studying practice patterns; and
       ``(B) collecting and reporting data on performance measures 
     developed under sections 749(d)(3), 757(d)(3), and 762(a)(3).
       ``(3) Guidelines.--A longitudinal evaluation shall comply 
     with guidelines issued under sections 749(d)(4), 757(d)(4), 
     and 762(a)(4).
       ``(4) Eligible entities.--To be eligible to obtain an 
     increase under this section, an entity shall be a recipient 
     of a grant or contract under this title.''; and
       (3) in subsection (e), as so redesignated--
       (A) by striking paragraph (1) and inserting the following:
       ``(1) In general.--
       ``(A) National center.--To carry out subsection (b), there 
     are authorized to be appropriated $7,500,000 for each of 
     fiscal years 2010 through 2014.
       ``(B) State and regional centers.--To carry out subsection 
     (c), there are authorized to be appropriated $4,500,000 for 
     each of fiscal years 2010 through 2014.
       ``(C) Grants for longitudinal evaluations.--To carry out 
     subsection (d), there are authorized to be appropriated such 
     sums as may be necessary for fiscal years 2010 through 
     2014.''; and
       (4) in paragraph (2), by striking ``subsection (a)'' and 
     inserting ``paragraph (1)''.
       (b) Transfers.--Not later than 180 days after the date of 
     enactment of this Act, the responsibilities and resources of 
     the National Center for Health Workforce Analysis, as in 
     effect on the date before the date of enactment of this Act, 
     shall be transferred to the National Center for Health Care 
     Workforce Analysis established under section 761 of the 
     Public Health Service Act, as amended by subsection (a).
       (c) Use of Longitudinal Evaluations.--Section 791(a)(1) of 
     the Public Health Service Act (42 U.S.C. 295j(a)(1)) is 
     amended--
       (1) in subparagraph (A), by striking ``or'' at the end;
       (2) in subparagraph (B), by striking the period and 
     inserting ``; or''; and
       (3) by adding at the end the following:
       ``(C) utilizes a longitudinal evaluation (as described in 
     section 761(d)(2)) and reports data from such system to the 
     national workforce database (as established under section 
     761(b)(2)(E)).''.
       (d) Performance Measures; Guidelines for Longitudinal 
     Evaluations.--
       (1) Advisory committee on training in primary care medicine 
     and dentistry.--Section 748(d) of the Public Health Service 
     Act is amended--
       (A) in paragraph (1), by striking ``and'' at the end;
       (B) in paragraph (2), by striking the period and inserting 
     a semicolon; and
       (C) by adding at the end the following:
       ``(3) develop, publish, and implement performance measures 
     for programs under this part;
       ``(4) develop and publish guidelines for longitudinal 
     evaluations (as described in section 761(d)(2)) for programs 
     under this part; and
       ``(5) recommend appropriation levels for programs under 
     this part.''.
       (2) Advisory committee on interdisciplinary, community-
     based linkages.--Section 756(d) of the Public Health Service 
     Act is amended--
       (A) in paragraph (1), by striking ``and'' at the end;
       (B) in paragraph (2), by striking the period and inserting 
     a semicolon; and
       (C) by adding at the end the following:
       ``(3) develop, publish, and implement performance measures 
     for programs under this part;
       ``(4) develop and publish guidelines for longitudinal 
     evaluations (as described in section 761(d)(2)) for programs 
     under this part; and
       ``(5) recommend appropriation levels for programs under 
     this part.''.
       (3) Advisory council on graduate medical education.--
     Section 762(a) of the Public Health Service Act (42 U.S.C. 
     294o(a)) is amended--
       (A) in paragraph (1), by striking ``and'' at the end;
       (B) in paragraph (2), by striking the period and inserting 
     a semicolon; and
       (C) by adding at the end the following:
       ``(3) develop, publish, and implement performance measures 
     for programs under this title, except for programs under part 
     C or D;
       ``(4) develop and publish guidelines for longitudinal 
     evaluations (as described in section 761(d)(2)) for programs 
     under this title, except for programs under part C or D; and
       ``(5) recommend appropriation levels for programs under 
     this title, except for programs under part C or D.''.

     Subtitle C--Increasing the Supply of the Health Care Workforce

     SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS.

       (a) Medical Schools and Primary Health Care.--Section 723 
     of the Public Health Service Act (42 U.S.C. 292s) is 
     amended--
       (1) in subsection (a)--
       (A) in paragraph (1), by striking subparagraph (B) and 
     inserting the following:
       ``(B) to practice in such care for 10 years (including 
     residency training in primary health care) or through the 
     date on which the loan is repaid in full, whichever occurs 
     first.''; and
       (B) by striking paragraph (3) and inserting the following:
       ``(3) Noncompliance by student.--Each agreement entered 
     into with a student pursuant to paragraph (1) shall provide 
     that, if the student fails to comply with such agreement, the 
     loan involved will begin to accrue interest at a rate of 2 
     percent per year greater than the rate at which the student 
     would pay if compliant in such year.''; and
       (2) by adding at the end the following:
       ``(d) Sense of Congress.--It is the sense of Congress that 
     funds repaid under the loan program under this section should 
     not be transferred to the Treasury of the United States or 
     otherwise used for any other purpose other than to carry out 
     this section.''.
       (b) Student Loan Guidelines.--The Secretary of Health and 
     Human Services shall not require parental financial 
     information for an independent student to determine financial 
     need under section 723 of the Public Health Service Act (42 
     U.S.C. 292s) and the determination of need for such 
     information shall be at the discretion of applicable school 
     loan officer. The Secretary shall amend guidelines issued by 
     the Health Resources and Services Administration in 
     accordance with the preceding sentence.

     SEC. 5202. NURSING STUDENT LOAN PROGRAM.

       (a) Loan Agreements.--Section 836(a) of the Public Health 
     Service Act (42 U.S.C. 297b(a)) is amended--
       (1) by striking ``$2,500'' and inserting ``$3,300'';
       (2) by striking ``$4,000'' and inserting ``$5,200''; and
       (3) by striking ``$13,000'' and all that follows through 
     the period and inserting ``$17,000 in the case of any student 
     during fiscal years 2010 and 2011. After fiscal year 2011, 
     such amounts shall be adjusted to provide for a cost-of-
     attendance increase for the yearly loan rate and the 
     aggregate of the loans.''.
       (b) Loan Provisions.--Section 836(b) of the Public Health 
     Service Act (42 U.S.C. 297b(b)) is amended--
       (1) in paragraph (1)(C), by striking ``1986'' and inserting 
     ``2000''; and
       (2) in paragraph (3), by striking ``the date of enactment 
     of the Nurse Training Amendments of 1979'' and inserting 
     ``September 29, 1995''.

     SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS.

       Part E of title VII of the Public Health Service Act (42 
     U.S.C. 294n et seq.) is amended by adding at the end the 
     following:

            ``Subpart 3--Recruitment and Retention Programs

     ``SEC. 775. INVESTMENT IN TOMORROW'S PEDIATRIC HEALTH CARE 
                   WORKFORCE.

       ``(a) Establishment.--The Secretary shall establish and 
     carry out a pediatric specialty loan repayment program under 
     which the eligible individual agrees to be employed full-time 
     for a specified period (which shall not be less than 2 years) 
     in providing pediatric medical subspecialty, pediatric 
     surgical specialty, or child and adolescent mental and 
     behavioral health care, including substance abuse prevention 
     and treatment services.
       ``(b) Program Administration.--Through the program 
     established under this section, the Secretary shall enter 
     into contracts with qualified health professionals under 
     which--
       ``(1) such qualified health professionals will agree to 
     provide pediatric medical subspecialty, pediatric surgical 
     specialty, or child and adolescent mental and behavioral 
     health care in an area with a shortage of the specified 
     pediatric subspecialty that has a sufficient pediatric 
     population to support such pediatric subspecialty, as 
     determined by the Secretary; and

[[Page 4334]]

       ``(2) the Secretary agrees to make payments on the 
     principal and interest of undergraduate, graduate, or 
     graduate medical education loans of professionals described 
     in paragraph (1) of not more than $35,000 a year for each 
     year of agreed upon service under such paragraph for a period 
     of not more than 3 years during the qualified health 
     professional's--
       ``(A) participation in an accredited pediatric medical 
     subspecialty, pediatric surgical specialty, or child and 
     adolescent mental health subspecialty residency or 
     fellowship; or
       ``(B) employment as a pediatric medical subspecialist, 
     pediatric surgical specialist, or child and adolescent mental 
     health professional serving an area or population described 
     in such paragraph.
       ``(c) In General.--
       ``(1) Eligible individuals.--
       ``(A) Pediatric medical specialists and pediatric surgical 
     specialists.--For purposes of contracts with respect to 
     pediatric medical specialists and pediatric surgical 
     specialists, the term `qualified health professional' means a 
     licensed physician who--
       ``(i) is entering or receiving training in an accredited 
     pediatric medical subspecialty or pediatric surgical 
     specialty residency or fellowship; or
       ``(ii) has completed (but not prior to the end of the 
     calendar year in which this section is enacted) the training 
     described in subparagraph (B).
       ``(B) Child and adolescent mental and behavioral health.--
     For purposes of contracts with respect to child and 
     adolescent mental and behavioral health care, the term 
     `qualified health professional' means a health care 
     professional who--
       ``(i) has received specialized training or clinical 
     experience in child and adolescent mental health in 
     psychiatry, psychology, school psychology, behavioral 
     pediatrics, psychiatric nursing, social work, school social 
     work, substance abuse disorder prevention and treatment, 
     marriage and family therapy, school counseling, or 
     professional counseling;
       ``(ii) has a license or certification in a State to 
     practice allopathic medicine, osteopathic medicine, 
     psychology, school psychology, psychiatric nursing, social 
     work, school social work, marriage and family therapy, school 
     counseling, or professional counseling; or
       ``(iii) is a mental health service professional who 
     completed (but not before the end of the calendar year in 
     which this section is enacted) specialized training or 
     clinical experience in child and adolescent mental health 
     described in clause (i).
       ``(2) Additional eligibility requirements.--The Secretary 
     may not enter into a contract under this subsection with an 
     eligible individual unless--
       ``(A) the individual agrees to work in, or for a provider 
     serving, a health professional shortage area or medically 
     underserved area, or to serve a medically underserved 
     population;
       ``(B) the individual is a United States citizen or a 
     permanent legal United States resident; and
       ``(C) if the individual is enrolled in a graduate program, 
     the program is accredited, and the individual has an 
     acceptable level of academic standing (as determined by the 
     Secretary).
       ``(d) Priority.--In entering into contracts under this 
     subsection, the Secretary shall give priority to applicants 
     who--
       ``(1) are or will be working in a school or other pre-
     kindergarten, elementary, or secondary education setting;
       ``(2) have familiarity with evidence-based methods and 
     cultural and linguistic competence health care services; and
       ``(3) demonstrate financial need.
       ``(e) Authorization of Appropriations.--There is authorized 
     to be appropriated $30,000,000 for each of fiscal years 2010 
     through 2014 to carry out subsection (c)(1)(A) and 
     $20,000,000 for each of fiscal years 2010 through 2013 to 
     carry out subsection (c)(1)(B).''.

     SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION 
                   PROGRAMS.

       Part E of title VII of the Public Health Service Act (42 
     U.S.C. 294n et seq.), as amended by section 5203, is further 
     amended by adding at the end the following:

     ``SEC. 776. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.

       ``(a) Establishment.--The Secretary shall establish the 
     Public Health Workforce Loan Repayment Program (referred to 
     in this section as the `Program') to assure an adequate 
     supply of public health professionals to eliminate critical 
     public health workforce shortages in Federal, State, local, 
     and tribal public health agencies.
       ``(b) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1)(A) be accepted for enrollment, or be enrolled, as a 
     student in an accredited academic educational institution in 
     a State or territory in the final year of a course of study 
     or program leading to a public health or health professions 
     degree or certificate; and have accepted employment with a 
     Federal, State, local, or tribal public health agency, or a 
     related training fellowship, as recognized by the Secretary, 
     to commence upon graduation;
       ``(B)(i) have graduated, during the preceding 10-year 
     period, from an accredited educational institution in a State 
     or territory and received a public health or health 
     professions degree or certificate; and
       ``(ii) be employed by, or have accepted employment with, a 
     Federal, State, local, or tribal public health agency or a 
     related training fellowship, as recognized by the Secretary;
       ``(2) be a United States citizen; and
       ``(3)(A) submit an application to the Secretary to 
     participate in the Program;
       ``(B) execute a written contract as required in subsection 
     (c); and
       ``(4) not have received, for the same service, a reduction 
     of loan obligations under section 455(m), 428J, 428K, 428L, 
     or 460 of the Higher Education Act of 1965.
       ``(c) Contract.--The written contract (referred to in this 
     section as the `written contract') between the Secretary and 
     an individual shall contain--
       ``(1) an agreement on the part of the Secretary that the 
     Secretary will repay on behalf of the individual loans 
     incurred by the individual in the pursuit of the relevant 
     degree or certificate in accordance with the terms of the 
     contract;
       ``(2) an agreement on the part of the individual that the 
     individual will serve in the full-time employment of a 
     Federal, State, local, or tribal public health agency or a 
     related fellowship program in a position related to the 
     course of study or program for which the contract was awarded 
     for a period of time (referred to in this section as the 
     `period of obligated service') equal to the greater of--
       ``(A) 3 years; or
       ``(B) such longer period of time as determined appropriate 
     by the Secretary and the individual;
       ``(3) an agreement, as appropriate, on the part of the 
     individual to relocate to a priority service area (as 
     determined by the Secretary) in exchange for an additional 
     loan repayment incentive amount to be determined by the 
     Secretary;
       ``(4) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this section and any obligation of the individual that is 
     conditioned thereon, is contingent on funds being 
     appropriated for loan repayments under this section;
       ``(5) a statement of the damages to which the United States 
     is entitled, under this section for the individual's breach 
     of the contract; and
       ``(6) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     this section.
       ``(d) Payments.--
       ``(1) In general.--A loan repayment provided for an 
     individual under a written contract under the Program shall 
     consist of payment, in accordance with paragraph (2), on 
     behalf of the individual of the principal, interest, and 
     related expenses on government and commercial loans received 
     by the individual regarding the undergraduate or graduate 
     education of the individual (or both), which loans were made 
     for tuition expenses incurred by the individual.
       ``(2) Payments for years served.--For each year of 
     obligated service that an individual contracts to serve under 
     subsection (c) the Secretary may pay up to $35,000 on behalf 
     of the individual for loans described in paragraph (1). With 
     respect to participants under the Program whose total 
     eligible loans are less than $105,000, the Secretary shall 
     pay an amount that does not exceed \1/3\ of the eligible loan 
     balance for each year of obligated service of the individual.
       ``(3) Tax liability.--For the purpose of providing 
     reimbursements for tax liability resulting from payments 
     under paragraph (2) on behalf of an individual, the Secretary 
     shall, in addition to such payments, make payments to the 
     individual in an amount not to exceed 39 percent of the total 
     amount of loan repayments made for the taxable year involved.
       ``(e) Postponing Obligated Service.--With respect to an 
     individual receiving a degree or certificate from a health 
     professions or other related school, the date of the 
     initiation of the period of obligated service may be 
     postponed as approved by the Secretary.
       ``(f) Breach of Contract.--An individual who fails to 
     comply with the contract entered into under subsection (c) 
     shall be subject to the same financial penalties as provided 
     for under section 338E for breaches of loan repayment 
     contracts under section 338B.
       ``(g) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $195,000,000 for 
     fiscal year 2010, and such sums as may be necessary for each 
     of fiscal years 2011 through 2015.''.

     SEC. 5205. ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION 
                   PROGRAMS.

       (a) Purpose.--The purpose of this section is to assure an 
     adequate supply of allied health professionals to eliminate 
     critical allied health workforce shortages in Federal, State, 
     local, and tribal public health agencies or in settings where 
     patients might require health care services, including acute 
     care facilities, ambulatory care facilities, personal 
     residences and other settings, as recognized by the Secretary 
     of Health and Human Services by authorizing an Allied Health 
     Loan Forgiveness Program.
       (b) Allied Health Workforce Recruitment and Retention 
     Program.--Section 428K of the Higher Education Act of 1965 
     (20 U.S.C. 1078-11) is amended--
       (1) in subsection (b), by adding at the end the following:
       ``(18) Allied health professionals.--The individual is 
     employed full-time as an allied health professional--
       ``(A) in a Federal, State, local, or tribal public health 
     agency; or
       ``(B) in a setting where patients might require health care 
     services, including acute care facilities, ambulatory care 
     facilities, personal residences and other settings located in 
     health professional shortage areas, medically underserved 
     areas, or medically underserved populations, as recognized by 
     the Secretary of Health and Human Services.''; and
       (2) in subsection (g)--
       (A) by redesignating paragraphs (1) through (9) as 
     paragraphs (2) through (10), respectively; and

[[Page 4335]]

       (B) by inserting before paragraph (2) (as redesignated by 
     subparagraph (A)) the following:
       ``(1) Allied health professional.--The term `allied health 
     professional' means an allied health professional as defined 
     in section 799B(5) of the Public Heath Service Act (42 U.S.C. 
     295p(5)) who--
       ``(A) has graduated and received an allied health 
     professions degree or certificate from an institution of 
     higher education; and
       ``(B) is employed with a Federal, State, local or tribal 
     public health agency, or in a setting where patients might 
     require health care services, including acute care 
     facilities, ambulatory care facilities, personal residences 
     and other settings located in health professional shortage 
     areas, medically underserved areas, or medically underserved 
     populations, as recognized by the Secretary of Health and 
     Human Services.''.

     SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS.

       (a) In General.--Section 765(d) of the Public Health 
     Service Act (42 U.S.C. 295(d)) is amended--
       (1) in paragraph (7), by striking ``; or'' and inserting a 
     semicolon;
       (2) by redesignating paragraph (8) as paragraph (9); and
       (3) by inserting after paragraph (7) the following:
       ``(8) public health workforce loan repayment programs; 
     or''.
       (b) Training for Mid-career Public Health Professionals.--
     Part E of title VII of the Public Health Service Act (42 
     U.S.C. 294n et seq.), as amended by section 5204, is further 
     amended by adding at the end the following:

     ``SEC. 777. TRAINING FOR MID-CAREER PUBLIC AND ALLIED HEALTH 
                   PROFESSIONALS.

       ``(a) In General.--The Secretary may make grants to, or 
     enter into contracts with, any eligible entity to award 
     scholarships to eligible individuals to enroll in degree or 
     professional training programs for the purpose of enabling 
     mid-career professionals in the public health and allied 
     health workforce to receive additional training in the field 
     of public health and allied health.
       ``(b) Eligibility.--
       ``(1) Eligible entity.--The term `eligible entity' 
     indicates an accredited educational institution that offers a 
     course of study, certificate program, or professional 
     training program in public or allied health or a related 
     discipline, as determined by the Secretary
       ``(2) Eligible individuals.--The term `eligible 
     individuals' includes those individuals employed in public 
     and allied health positions at the Federal, State, tribal, or 
     local level who are interested in retaining or upgrading 
     their education.
       ``(c) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $60,000,000 for 
     fiscal year 2010 and such sums as may be necessary for each 
     of fiscal years 2011 through 2015. Fifty percent of 
     appropriated funds shall be allotted to public health mid-
     career professionals and 50 percent shall be allotted to 
     allied health mid-career professionals.''.

     SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS.

       Section 338H(a) of the Public Health Service Act (42 U.S.C. 
     254q(a)) is amended to read as follows:
       ``(a) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there is authorized to be 
     appropriated, out of any funds in the Treasury not otherwise 
     appropriated, the following:
       ``(1) For fiscal year 2010, $320,461,632.
       ``(2) For fiscal year 2011, $414,095,394.
       ``(3) For fiscal year 2012, $535,087,442.
       ``(4) For fiscal year 2013, $691,431,432.
       ``(5) For fiscal year 2014, $893,456,433.
       ``(6) For fiscal year 2015, $1,154,510,336.
       ``(7) For fiscal year 2016, and each subsequent fiscal 
     year, the amount appropriated for the preceding fiscal year 
     adjusted by the product of--
       ``(A) one plus the average percentage increase in the costs 
     of health professions education during the prior fiscal year; 
     and
       ``(B) one plus the average percentage change in the number 
     of individuals residing in health professions shortage areas 
     designated under section 333 during the prior fiscal year, 
     relative to the number of individuals residing in such areas 
     during the previous fiscal year.''.

     SEC. 5208. NURSE-MANAGED HEALTH CLINICS.

       (a) Purpose.--The purpose of this section is to fund the 
     development and operation of nurse-managed health clinics.
       (b) Grants.--Subpart 1 of part D of title III of the Public 
     Health Service Act (42 U.S.C. 254b et seq.) is amended by 
     inserting after section 330A the following:

     ``SEC. 330A-1. GRANTS TO NURSE-MANAGED HEALTH CLINICS.

       ``(a) Definitions.--
       ``(1) Comprehensive primary health care services.--In this 
     section, the term `comprehensive primary health care 
     services' means the primary health services described in 
     section 330(b)(1).
       ``(2) Nurse-managed health clinic.--The term `nurse-managed 
     health clinic' means a nurse-practice arrangement, managed by 
     advanced practice nurses, that provides primary care or 
     wellness services to underserved or vulnerable populations 
     and that is associated with a school, college, university or 
     department of nursing, federally qualified health center, or 
     independent nonprofit health or social services agency.
       ``(b) Authority to Award Grants.--The Secretary shall award 
     grants for the cost of the operation of nurse-managed health 
     clinics that meet the requirements of this section.
       ``(c) Applications.--To be eligible to receive a grant 
     under this section, an entity shall--
       ``(1) be an NMHC; and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing--
       ``(A) assurances that nurses are the major providers of 
     services at the NMHC and that at least 1 advanced practice 
     nurse holds an executive management position within the 
     organizational structure of the NMHC;
       ``(B) an assurance that the NMHC will continue providing 
     comprehensive primary health care services or wellness 
     services without regard to income or insurance status of the 
     patient for the duration of the grant period; and
       ``(C) an assurance that, not later than 90 days of 
     receiving a grant under this section, the NMHC will establish 
     a community advisory committee, for which a majority of the 
     members shall be individuals who are served by the NMHC.
       ``(d) Grant Amount.--The amount of any grant made under 
     this section for any fiscal year shall be determined by the 
     Secretary, taking into account--
       ``(1) the financial need of the NMHC, considering State, 
     local, and other operational funding provided to the NMHC; 
     and
       ``(2) other factors, as the Secretary determines 
     appropriate.
       ``(e) Authorization of Appropriations.--For the purposes of 
     carrying out this section, there are authorized to be 
     appropriated $50,000,000 for the fiscal year 2010 and such 
     sums as may be necessary for each of the fiscal years 2011 
     through 2014.''.

     SEC. 5209. ELIMINATION OF CAP ON COMMISSIONED CORPS.

       Section 202 of the Department of Health and Human Services 
     Appropriations Act, 1993 (Public Law 102-394) is amended by 
     striking ``not to exceed 2,800''.

     SEC. 5210. ESTABLISHING A READY RESERVE CORPS.

       Section 203 of the Public Health Service Act (42 U.S.C. 
     204) is amended to read as follows:

     ``SEC. 203. COMMISSIONED CORPS AND READY RESERVE CORPS.

       ``(a) Establishment.--
       ``(1) In general.--There shall be in the Service a 
     commissioned Regular Corps and a Ready Reserve Corps for 
     service in time of national emergency.
       ``(2) Requirement.--All commissioned officers shall be 
     citizens of the United States and shall be appointed without 
     regard to the civil-service laws and compensated without 
     regard to the Classification Act of 1923, as amended.
       ``(3) Appointment.--Commissioned officers of the Ready 
     Reserve Corps shall be appointed by the President and 
     commissioned officers of the Regular Corps shall be appointed 
     by the President with the advice and consent of the Senate.
       ``(4) Active duty.--Commissioned officers of the Ready 
     Reserve Corps shall at all times be subject to call to active 
     duty by the Surgeon General, including active duty for the 
     purpose of training.
       ``(5) Warrant officers.--Warrant officers may be appointed 
     to the Service for the purpose of providing support to the 
     health and delivery systems maintained by the Service and any 
     warrant officer appointed to the Service shall be considered 
     for purposes of this Act and title 37, United States Code, to 
     be a commissioned officer within the Commissioned Corps of 
     the Service.
       ``(b) Assimilating Reserve Corp Officers Into the Regular 
     Corps.--Effective on the date of enactment of the Patient 
     Protection and Affordable Care Act, all individuals 
     classified as officers in the Reserve Corps under this 
     section (as such section existed on the day before the date 
     of enactment of such Act) and serving on active duty shall be 
     deemed to be commissioned officers of the Regular Corps.
       ``(c) Purpose and Use of Ready Research.--
       ``(1) Purpose.--The purpose of the Ready Reserve Corps is 
     to fulfill the need to have additional Commissioned Corps 
     personnel available on short notice (similar to the uniformed 
     service's reserve program) to assist regular Commissioned 
     Corps personnel to meet both routine public health and 
     emergency response missions.
       ``(2) Uses.--The Ready Reserve Corps shall--
       ``(A) participate in routine training to meet the general 
     and specific needs of the Commissioned Corps;
       ``(B) be available and ready for involuntary calls to 
     active duty during national emergencies and public health 
     crises, similar to the uniformed service reserve personnel;
       ``(C) be available for backfilling critical positions left 
     vacant during deployment of active duty Commissioned Corps 
     members, as well as for deployment to respond to public 
     health emergencies, both foreign and domestic; and
       ``(D) be available for service assignment in isolated, 
     hardship, and medically underserved communities (as defined 
     in section 799B) to improve access to health services.
       ``(d) Funding.--For the purpose of carrying out the duties 
     and responsibilities of the Commissioned Corps under this 
     section, there are authorized to be appropriated $5,000,000 
     for each of fiscal years 2010 through 2014 for recruitment 
     and training and $12,500,000 for each of fiscal years 2010 
     through 2014 for the Ready Reserve Corps.''.

[[Page 4336]]



   Subtitle D--Enhancing Health Care Workforce Education and Training

     SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL 
                   MEDICINE, GENERAL PEDIATRICS, AND PHYSICIAN 
                   ASSISTANTSHIP.

       Part C of title VII (42 U.S.C. 293k et seq.) is amended by 
     striking section 747 and inserting the following:

     ``SEC. 747. PRIMARY CARE TRAINING AND ENHANCEMENT.

       ``(a) Support and Development of Primary Care Training 
     Programs.--
       ``(1) In general.--The Secretary may make grants to, or 
     enter into contracts with, an accredited public or nonprofit 
     private hospital, school of medicine or osteopathic medicine, 
     academically affiliated physician assistant training program, 
     or a public or private nonprofit entity which the Secretary 
     has determined is capable of carrying out such grant or 
     contract--
       ``(A) to plan, develop, operate, or participate in an 
     accredited professional training program, including an 
     accredited residency or internship program in the field of 
     family medicine, general internal medicine, or general 
     pediatrics for medical students, interns, residents, or 
     practicing physicians as defined by the Secretary;
       ``(B) to provide need-based financial assistance in the 
     form of traineeships and fellowships to medical students, 
     interns, residents, practicing physicians, or other medical 
     personnel, who are participants in any such program, and who 
     plan to specialize or work in the practice of the fields 
     defined in subparagraph (A);
       ``(C) to plan, develop, and operate a program for the 
     training of physicians who plan to teach in family medicine, 
     general internal medicine, or general pediatrics training 
     programs;
       ``(D) to plan, develop, and operate a program for the 
     training of physicians teaching in community-based settings;
       ``(E) to provide financial assistance in the form of 
     traineeships and fellowships to physicians who are 
     participants in any such programs and who plan to teach or 
     conduct research in a family medicine, general internal 
     medicine, or general pediatrics training program;
       ``(F) to plan, develop, and operate a physician assistant 
     education program, and for the training of individuals who 
     will teach in programs to provide such training;
       ``(G) to plan, develop, and operate a demonstration program 
     that provides training in new competencies, as recommended by 
     the Advisory Committee on Training in Primary Care Medicine 
     and Dentistry and the National Health Care Workforce 
     Commission established in section 5101 of the Patient 
     Protection and Affordable Care Act, which may include--
       ``(i) providing training to primary care physicians 
     relevant to providing care through patient-centered medical 
     homes (as defined by the Secretary for purposes of this 
     section);
       ``(ii) developing tools and curricula relevant to patient-
     centered medical homes; and
       ``(iii) providing continuing education to primary care 
     physicians relevant to patient-centered medical homes; and
       ``(H) to plan, develop, and operate joint degree programs 
     to provide interdisciplinary and interprofessional graduate 
     training in public health and other health professions to 
     provide training in environmental health, infectious disease 
     control, disease prevention and health promotion, 
     epidemiological studies and injury control.
       ``(2) Duration of awards.--The period during which payments 
     are made to an entity from an award of a grant or contract 
     under this subsection shall be 5 years.
       ``(b) Capacity Building in Primary Care.--
       ``(1) In general.--The Secretary may make grants to or 
     enter into contracts with accredited schools of medicine or 
     osteopathic medicine to establish, maintain, or improve--
       ``(A) academic units or programs that improve clinical 
     teaching and research in fields defined in subsection 
     (a)(1)(A); or
       ``(B) programs that integrate academic administrative units 
     in fields defined in subsection (a)(1)(A) to enhance 
     interdisciplinary recruitment, training, and faculty 
     development.
       ``(2) Preference in making awards under this subsection.--
     In making awards of grants and contracts under paragraph (1), 
     the Secretary shall give preference to any qualified 
     applicant for such an award that agrees to expend the award 
     for the purpose of--
       ``(A) establishing academic units or programs in fields 
     defined in subsection (a)(1)(A); or
       ``(B) substantially expanding such units or programs.
       ``(3) Priorities in making awards.--In awarding grants or 
     contracts under paragraph (1), the Secretary shall give 
     priority to qualified applicants that--
       ``(A) proposes a collaborative project between academic 
     administrative units of primary care;
       ``(B) proposes innovative approaches to clinical teaching 
     using models of primary care, such as the patient centered 
     medical home, team management of chronic disease, and 
     interprofessional integrated models of health care that 
     incorporate transitions in health care settings and 
     integration physical and mental health provision;
       ``(C) have a record of training the greatest percentage of 
     providers, or that have demonstrated significant improvements 
     in the percentage of providers trained, who enter and remain 
     in primary care practice;
       ``(D) have a record of training individuals who are from 
     underrepresented minority groups or from a rural or 
     disadvantaged background;
       ``(E) provide training in the care of vulnerable 
     populations such as children, older adults, homeless 
     individuals, victims of abuse or trauma, individuals with 
     mental health or substance-related disorders, individuals 
     with HIV/AIDS, and individuals with disabilities;
       ``(F) establish formal relationships and submit joint 
     applications with federally qualified health centers, rural 
     health clinics, area health education centers, or clinics 
     located in underserved areas or that serve underserved 
     populations;
       ``(G) teach trainees the skills to provide 
     interprofessional, integrated care through collaboration 
     among health professionals;
       ``(H) provide training in enhanced communication with 
     patients, evidence-based practice, chronic disease 
     management, preventive care, health information technology, 
     or other competencies as recommended by the Advisory 
     Committee on Training in Primary Care Medicine and Dentistry 
     and the National Health Care Workforce Commission established 
     in section 5101 of the Patient Protection and Affordable Care 
     Act; or
       ``(I) provide training in cultural competency and health 
     literacy.
       ``(4) Duration of awards.--The period during which payments 
     are made to an entity from an award of a grant or contract 
     under this subsection shall be 5 years.
       ``(c) Authorization of Appropriations.--
       ``(1) In general.--For purposes of carrying out this 
     section (other than subsection (b)(1)(B)), there are 
     authorized to be appropriated $125,000,000 for fiscal year 
     2010, and such sums as may be necessary for each of fiscal 
     years 2011 through 2014.
       ``(2) Training programs.--Fifteen percent of the amount 
     appropriated pursuant to paragraph (1) in each such fiscal 
     year shall be allocated to the physician assistant training 
     programs described in subsection (a)(1)(F), which prepare 
     students for practice in primary care.
       ``(3) Integrating academic administrative units.--For 
     purposes of carrying out subsection (b)(1)(B), there are 
     authorized to be appropriated $750,000 for each of fiscal 
     years 2010 through 2014.''.

     SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.

       Part C of title VII of the Public Health Service Act (42 
     U.S.C. 293k et seq.) is amended by inserting after section 
     747, as amended by section 5301, the following:

     ``SEC. 747A. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS.

       ``(a) In General.--The Secretary shall award grants to 
     eligible entities to enable such entities to provide new 
     training opportunities for direct care workers who are 
     employed in long-term care settings such as nursing homes (as 
     defined in section 1908(e)(1) of the Social Security Act (42 
     U.S.C. 1396g(e)(1)), assisted living facilities and skilled 
     nursing facilities, intermediate care facilities for 
     individuals with mental retardation, home and community based 
     settings, and any other setting the Secretary determines to 
     be appropriate.
       ``(b) Eligibility.--To be eligible to receive a grant under 
     this section, an entity shall--
       ``(1) be an institution of higher education (as defined in 
     section 102 of the Higher Education Act of 1965 (20 U.S.C. 
     1002)) that--
       ``(A) is accredited by a nationally recognized accrediting 
     agency or association listed under section 101(c) of the 
     Higher Education Act of 1965 (20 U.S.C. 1001(c)); and
       ``(B) has established a public-private educational 
     partnership with a nursing home or skilled nursing facility, 
     agency or entity providing home and community based services 
     to individuals with disabilities, or other long-term care 
     provider; and
       ``(2) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(c) Use of Funds.--An eligible entity shall use amounts 
     awarded under a grant under this section to provide 
     assistance to eligible individuals to offset the cost of 
     tuition and required fees for enrollment in academic programs 
     provided by such entity.
       ``(d) Eligible Individual.--
       ``(1) Eligibility.--To be eligible for assistance under 
     this section, an individual shall be enrolled in courses 
     provided by a grantee under this subsection and maintain 
     satisfactory academic progress in such courses.
       ``(2) Condition of assistance.--As a condition of receiving 
     assistance under this section, an individual shall agree 
     that, following completion of the assistance period, the 
     individual will work in the field of geriatrics, disability 
     services, long term services and supports, or chronic care 
     management for a minimum of 2 years under guidelines set by 
     the Secretary.
       ``(e) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $10,000,000 for 
     the period of fiscal years 2011 through 2013.''.

     SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH 
                   DENTISTRY.

       Part C of Title VII of the Public Health Service Act (42 
     U.S.C. 293k et seq.) is amended by--
       (1) redesignating section 748, as amended by section 5103 
     of this Act, as section 749; and
       (2) inserting after section 747A, as added by section 5302, 
     the following:

     ``SEC. 748. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH 
                   DENTISTRY.

       ``(a) Support and Development of Dental Training 
     Programs.--
       ``(1) In general.--The Secretary may make grants to, or 
     enter into contracts with, a school of dentistry, public or 
     nonprofit private hospital, or a public or private nonprofit 
     entity which the Secretary has determined is capable of 
     carrying out such grant or contract--

[[Page 4337]]

       ``(A) to plan, develop, and operate, or participate in, an 
     approved professional training program in the field of 
     general dentistry, pediatric dentistry, or public health 
     dentistry for dental students, residents, practicing 
     dentists, dental hygienists, or other approved primary care 
     dental trainees, that emphasizes training for general, 
     pediatric, or public health dentistry;
       ``(B) to provide financial assistance to dental students, 
     residents, practicing dentists, and dental hygiene students 
     who are in need thereof, who are participants in any such 
     program, and who plan to work in the practice of general, 
     pediatric, public heath dentistry, or dental hygiene;
       ``(C) to plan, develop, and operate a program for the 
     training of oral health care providers who plan to teach in 
     general, pediatric, public health dentistry, or dental 
     hygiene;
       ``(D) to provide financial assistance in the form of 
     traineeships and fellowships to dentists who plan to teach or 
     are teaching in general, pediatric, or public health 
     dentistry;
       ``(E) to meet the costs of projects to establish, maintain, 
     or improve dental faculty development programs in primary 
     care (which may be departments, divisions or other units);
       ``(F) to meet the costs of projects to establish, maintain, 
     or improve predoctoral and postdoctoral training in primary 
     care programs;
       ``(G) to create a loan repayment program for faculty in 
     dental programs; and
       ``(H) to provide technical assistance to pediatric training 
     programs in developing and implementing instruction regarding 
     the oral health status, dental care needs, and risk-based 
     clinical disease management of all pediatric populations with 
     an emphasis on underserved children.
       ``(2) Faculty loan repayment.--
       ``(A) In general.--A grant or contract under subsection 
     (a)(1)(G) may be awarded to a program of general, pediatric, 
     or public health dentistry described in such subsection to 
     plan, develop, and operate a loan repayment program under 
     which--
       ``(i) individuals agree to serve full-time as faculty 
     members; and
       ``(ii) the program of general, pediatric or public health 
     dentistry agrees to pay the principal and interest on the 
     outstanding student loans of the individuals.
       ``(B) Manner of payments.--With respect to the payments 
     described in subparagraph (A)(ii), upon completion by an 
     individual of each of the first, second, third, fourth, and 
     fifth years of service, the program shall pay an amount equal 
     to 10, 15, 20, 25, and 30 percent, respectively, of the 
     individual's student loan balance as calculated based on 
     principal and interest owed at the initiation of the 
     agreement.
       ``(b) Eligible Entity.--For purposes of this subsection, 
     entities eligible for such grants or contracts in general, 
     pediatric, or public health dentistry shall include entities 
     that have programs in dental or dental hygiene schools, or 
     approved residency or advanced education programs in the 
     practice of general, pediatric, or public health dentistry. 
     Eligible entities may partner with schools of public health 
     to permit the education of dental students, residents, and 
     dental hygiene students for a master's year in public health 
     at a school of public health.
       ``(c) Priorities in Making Awards.--With respect to 
     training provided for under this section, the Secretary shall 
     give priority in awarding grants or contracts to the 
     following:
       ``(1) Qualified applicants that propose collaborative 
     projects between departments of primary care medicine and 
     departments of general, pediatric, or public health 
     dentistry.
       ``(2) Qualified applicants that have a record of training 
     the greatest percentage of providers, or that have 
     demonstrated significant improvements in the percentage of 
     providers, who enter and remain in general, pediatric, or 
     public health dentistry.
       ``(3) Qualified applicants that have a record of training 
     individuals who are from a rural or disadvantaged background, 
     or from underrepresented minorities.
       ``(4) Qualified applicants that establish formal 
     relationships with Federally qualified health centers, rural 
     health centers, or accredited teaching facilities and that 
     conduct training of students, residents, fellows, or faculty 
     at the center or facility.
       ``(5) Qualified applicants that conduct teaching programs 
     targeting vulnerable populations such as older adults, 
     homeless individuals, victims of abuse or trauma, individuals 
     with mental health or substance-related disorders, 
     individuals with disabilities, and individuals with HIV/AIDS, 
     and in the risk-based clinical disease management of all 
     populations.
       ``(6) Qualified applicants that include educational 
     activities in cultural competency and health literacy.
       ``(7) Qualified applicants that have a high rate for 
     placing graduates in practice settings that serve underserved 
     areas or health disparity populations, or who achieve a 
     significant increase in the rate of placing graduates in such 
     settings.
       ``(8) Qualified applicants that intend to establish a 
     special populations oral health care education center or 
     training program for the didactic and clinical education of 
     dentists, dental health professionals, and dental hygienists 
     who plan to teach oral health care for people with 
     developmental disabilities, cognitive impairment, complex 
     medical problems, significant physical limitations, and 
     vulnerable elderly.
       ``(d) Application.--An eligible entity desiring a grant 
     under this section shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(e) Duration of Award.--The period during which payments 
     are made to an entity from an award of a grant or contract 
     under subsection (a) shall be 5 years. The provision of such 
     payments shall be subject to annual approval by the Secretary 
     and subject to the availability of appropriations for the 
     fiscal year involved to make the payments.
       ``(f) Authorizations of Appropriations.--For the purpose of 
     carrying out subsections (a) and (b), there is authorized to 
     be appropriated $30,000,000 for fiscal year 2010 and such 
     sums as may be necessary for each of fiscal years 2011 
     through 2015.
       ``(g) Carryover Funds.--An entity that receives an award 
     under this section may carry over funds from 1 fiscal year to 
     another without obtaining approval from the Secretary. In no 
     case may any funds be carried over pursuant to the preceding 
     sentence for more than 3 years.''.

     SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS 
                   DEMONSTRATION PROJECT.

       Subpart X of part D of title III of the Public Health 
     Service Act (42 U.S.C. 256f et seq.) is amended by adding at 
     the end the following:

     ``SEC. 340G-1. DEMONSTRATION PROGRAM.

       ``(a) In General.--
       ``(1) Authorization.--The Secretary is authorized to award 
     grants to 15 eligible entities to enable such entities to 
     establish a demonstration program to establish training 
     programs to train, or to employ, alternative dental health 
     care providers in order to increase access to dental health 
     care services in rural and other underserved communities.
       ``(2) Definition.--The term `alternative dental health care 
     providers' includes community dental health coordinators, 
     advance practice dental hygienists, independent dental 
     hygienists, supervised dental hygienists, primary care 
     physicians, dental therapists, dental health aides, and any 
     other health professional that the Secretary determines 
     appropriate.
       ``(b) Timeframe.--The demonstration projects funded under 
     this section shall begin not later than 2 years after the 
     date of enactment of this section, and shall conclude not 
     later than 7 years after such date of enactment.
       ``(c) Eligible Entities.--To be eligible to receive a grant 
     under subsection (a), an entity shall--
       ``(1) be--
       ``(A) an institution of higher education, including a 
     community college;
       ``(B) a public-private partnership;
       ``(C) a federally qualified health center;
       ``(D) an Indian Health Service facility or a tribe or 
     tribal organization (as such terms are defined in section 4 
     of the Indian Self-Determination and Education Assistance 
     Act);
       ``(E) a State or county public health clinic, a health 
     facility operated by an Indian tribe or tribal organization, 
     or urban Indian organization providing dental services; or
       ``(F) a public hospital or health system;
       ``(2) be within a program accredited by the Commission on 
     Dental Accreditation or within a dental education program in 
     an accredited institution; and
       ``(3) shall submit an application to the Secretary at such 
     time, in such manner, and containing such information as the 
     Secretary may require.
       ``(d) Administrative Provisions.--
       ``(1) Amount of grant.--Each grant under this section shall 
     be in an amount that is not less than $4,000,000 for the 5-
     year period during which the demonstration project being 
     conducted.
       ``(2) Disbursement of funds.--
       ``(A) Preliminary disbursements.--Beginning 1 year after 
     the enactment of this section, the Secretary may disperse to 
     any entity receiving a grant under this section not more than 
     20 percent of the total funding awarded to such entity under 
     such grant, for the purpose of enabling the entity to plan 
     the demonstration project to be conducted under such grant.
       ``(B) Subsequent disbursements.--The remaining amount of 
     grant funds not dispersed under subparagraph (A) shall be 
     dispersed such that not less than 15 percent of such 
     remaining amount is dispersed each subsequent year.
       ``(e) Compliance With State Requirements.--Each entity 
     receiving a grant under this section shall certify that it is 
     in compliance with all applicable State licensing 
     requirements.
       ``(f) Evaluation.--The Secretary shall contract with the 
     Director of the Institute of Medicine to conduct a study of 
     the demonstration programs conducted under this section that 
     shall provide analysis, based upon quantitative and 
     qualitative data, regarding access to dental health care in 
     the United States.
       ``(g) Clarification Regarding Dental Health Aide Program.--
     Nothing in this section shall prohibit a dental health aide 
     training program approved by the Indian Health Service from 
     being eligible for a grant under this section.
       ``(h) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.''.

     SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS; 
                   COMPREHENSIVE GERIATRIC EDUCATION.

       (a) Workforce Development; Career Awards.--Section 753 of 
     the Public Health Service Act (42 U.S.C. 294c) is amended by 
     adding at the end the following:
       ``(d) Geriatric Workforce Development.--
       ``(1) In general.--The Secretary shall award grants or 
     contracts under this subsection to entities that operate a 
     geriatric education center pursuant to subsection (a)(1).

[[Page 4338]]

       ``(2) Application.--To be eligible for an award under 
     paragraph (1), an entity described in such paragraph shall 
     submit to the Secretary an application at such time, in such 
     manner, and containing such information as the Secretary may 
     require.
       ``(3) Use of funds.--Amounts awarded under a grant or 
     contract under paragraph (1) shall be used to--
       ``(A) carry out the fellowship program described in 
     paragraph (4); and
       ``(B) carry out 1 of the 2 activities described in 
     paragraph (5).
       ``(4) Fellowship program.--
       ``(A) In general.--Pursuant to paragraph (3), a geriatric 
     education center that receives an award under this subsection 
     shall use such funds to offer short-term intensive courses 
     (referred to in this subsection as a `fellowship') that focus 
     on geriatrics, chronic care management, and long-term care 
     that provide supplemental training for faculty members in 
     medical schools and other health professions schools with 
     programs in psychology, pharmacy, nursing, social work, 
     dentistry, public health, allied health, or other health 
     disciplines, as approved by the Secretary. Such a fellowship 
     shall be open to current faculty, and appropriately 
     credentialed volunteer faculty and practitioners, who do not 
     have formal training in geriatrics, to upgrade their 
     knowledge and clinical skills for the care of older adults 
     and adults with functional limitations and to enhance their 
     interdisciplinary teaching skills.
       ``(B) Location.--A fellowship shall be offered either at 
     the geriatric education center that is sponsoring the course, 
     in collaboration with other geriatric education centers, or 
     at medical schools, schools of dentistry, schools of nursing, 
     schools of pharmacy, schools of social work, graduate 
     programs in psychology, or allied health and other health 
     professions schools approved by the Secretary with which the 
     geriatric education centers are affiliated.
       ``(C) CME credit.--Participation in a fellowship under this 
     paragraph shall be accepted with respect to complying with 
     continuing health profession education requirements. As a 
     condition of such acceptance, the recipient shall agree to 
     subsequently provide a minimum of 18 hours of voluntary 
     instructional support through a geriatric education center 
     that is providing clinical training to students or trainees 
     in long-term care settings.
       ``(5) Additional required activities described.--Pursuant 
     to paragraph (3), a geriatric education center that receives 
     an award under this subsection shall use such funds to carry 
     out 1 of the following 2 activities.
       ``(A) Family caregiver and direct care provider training.--
     A geriatric education center that receives an award under 
     this subsection shall offer at least 2 courses each year, at 
     no charge or nominal cost, to family caregivers and direct 
     care providers that are designed to provide practical 
     training for supporting frail elders and individuals with 
     disabilities. The Secretary shall require such Centers to 
     work with appropriate community partners to develop training 
     program content and to publicize the availability of training 
     courses in their service areas. All family caregiver and 
     direct care provider training programs shall include 
     instruction on the management of psychological and behavioral 
     aspects of dementia, communication techniques for working 
     with individuals who have dementia, and the appropriate, 
     safe, and effective use of medications for older adults.
       ``(B) Incorporation of best practices.--A geriatric 
     education center that receives an award under this subsection 
     shall develop and include material on depression and other 
     mental disorders common among older adults, medication safety 
     issues for older adults, and management of the psychological 
     and behavioral aspects of dementia and communication 
     techniques with individuals who have dementia in all training 
     courses, where appropriate.
       ``(6) Targets.--A geriatric education center that receives 
     an award under this subsection shall meet targets approved by 
     the Secretary for providing geriatric training to a certain 
     number of faculty or practitioners during the term of the 
     award, as well as other parameters established by the 
     Secretary.
       ``(7) Amount of award.--An award under this subsection 
     shall be in an amount of $150,000. Not more than 24 geriatric 
     education centers may receive an award under this subsection.
       ``(8) Maintenance of effort.--A geriatric education center 
     that receives an award under this subsection shall provide 
     assurances to the Secretary that funds provided to the 
     geriatric education center under this subsection will be used 
     only to supplement, not to supplant, the amount of Federal, 
     State, and local funds otherwise expended by the geriatric 
     education center.
       ``(9) Authorization of appropriations.--In addition to any 
     other funding available to carry out this section, there is 
     authorized to be appropriated to carry out this subsection, 
     $10,800,000 for the period of fiscal year 2011 through 2014.
       ``(e) Geriatric Career Incentive Awards.--
       ``(1) In general.--The Secretary shall award grants or 
     contracts under this section to individuals described in 
     paragraph (2) to foster greater interest among a variety of 
     health professionals in entering the field of geriatrics, 
     long-term care, and chronic care management.
       ``(2) Eligible individuals.--To be eligible to received an 
     award under paragraph (1), an individual shall--
       ``(A) be an advanced practice nurse, a clinical social 
     worker, a pharmacist, or student of psychology who is 
     pursuing a doctorate or other advanced degree in geriatrics 
     or related fields in an accredited health professions school; 
     and
       ``(B) submit to the Secretary an application at such time, 
     in such manner, and containing such information as the 
     Secretary may require.
       ``(3) Condition of award.--As a condition of receiving an 
     award under this subsection, an individual shall agree that, 
     following completion of the award period, the individual will 
     teach or practice in the field of geriatrics, long-term care, 
     or chronic care management for a minimum of 5 years under 
     guidelines set by the Secretary.
       ``(4) Authorization of appropriations.--There is authorized 
     to be appropriated to carry out this subsection, $10,000,000 
     for the period of fiscal years 2011 through 2013.''.
       (b) Expansion of Eligibility for Geriatric Academic Career 
     Awards; Payment to Institution.--Section 753(c) of the Public 
     Health Service Act 294(c)) is amended--
       (1) by redesignating paragraphs (4) and (5) as paragraphs 
     (5) and (6), respectively;
       (2) by striking paragraph (2) through paragraph (3) and 
     inserting the following:
       ``(2) Eligible individuals.--To be eligible to receive an 
     Award under paragraph (1), an individual shall--
       ``(A) be board certified or board eligible in internal 
     medicine, family practice, psychiatry, or licensed dentistry, 
     or have completed any required training in a discipline and 
     employed in an accredited health professions school that is 
     approved by the Secretary;
       ``(B) have completed an approved fellowship program in 
     geriatrics or have completed specialty training in geriatrics 
     as required by the discipline and any addition geriatrics 
     training as required by the Secretary; and
       ``(C) have a junior (non-tenured) faculty appointment at an 
     accredited (as determined by the Secretary) school of 
     medicine, osteopathic medicine, nursing, social work, 
     psychology, dentistry, pharmacy, or other allied health 
     disciplines in an accredited health professions school that 
     is approved by the Secretary.
       ``(3) Limitations.--No Award under paragraph (1) may be 
     made to an eligible individual unless the individual--
       ``(A) has submitted to the Secretary an application, at 
     such time, in such manner, and containing such information as 
     the Secretary may require, and the Secretary has approved 
     such application;
       ``(B) provides, in such form and manner as the Secretary 
     may require, assurances that the individual will meet the 
     service requirement described in paragraph (6); and
       ``(C) provides, in such form and manner as the Secretary 
     may require, assurances that the individual has a full-time 
     faculty appointment in a health professions institution and 
     documented commitment from such institution to spend 75 
     percent of the total time of such individual on teaching and 
     developing skills in interdisciplinary education in 
     geriatrics.
       ``(4) Maintenance of effort.--An eligible individual that 
     receives an Award under paragraph (1) shall provide 
     assurances to the Secretary that funds provided to the 
     eligible individual under this subsection will be used only 
     to supplement, not to supplant, the amount of Federal, State, 
     and local funds otherwise expended by the eligible 
     individual.''; and
       (3) in paragraph (5), as so designated--
       (A) in subparagraph (A)--
       (i) by inserting ``for individuals who are physicians'' 
     after ``this section''; and
       (ii) by inserting after the period at the end the 
     following: ``The Secretary shall determine the amount of an 
     Award under this section for individuals who are not 
     physicians.''; and
       (B) by adding at the end the following:
       ``(C) Payment to institution.--The Secretary shall make 
     payments to institutions which include schools of medicine, 
     osteopathic medicine, nursing, social work, psychology, 
     dentistry, and pharmacy, or other allied health discipline in 
     an accredited health professions school that is approved by 
     the Secretary.''.
       (c) Comprehensive Geriatric Education.--Section 855 of the 
     Public Health Service Act (42 U.S.C. 298) is amended--
       (1) in subsection (b)--
       (A) in paragraph (3), by striking ``or'' at the end;
       (B) in paragraph (4), by striking the period and inserting 
     ``; or''; and
       (C) by adding at the end the following:
       ``(5) establish traineeships for individuals who are 
     preparing for advanced education nursing degrees in geriatric 
     nursing, long-term care, gero-psychiatric nursing or other 
     nursing areas that specialize in the care of the elderly 
     population.''; and
       (2) in subsection (e), by striking ``2003 through 2007'' 
     and inserting ``2010 through 2014''.

     SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND 
                   TRAINING GRANTS.

       (a) In General.--Part D of title VII (42 U.S.C. 294 et 
     seq.) is amended by--
       (1) striking section 757;
       (2) redesignating section 756 (as amended by section 5103) 
     as section 757; and
       (3) inserting after section 755 the following:

     ``SEC. 756. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND 
                   TRAINING GRANTS.

       ``(a) Grants Authorized.--The Secretary may award grants to 
     eligible institutions of higher education to support the 
     recruitment of students for, and education and clinical 
     experience of the students in--
       ``(1) baccalaureate, master's, and doctoral degree programs 
     of social work, as well as the development of faculty in 
     social work;
       ``(2) accredited master's, doctoral, internship, and post-
     doctoral residency programs of psychology for the development 
     and implementation

[[Page 4339]]

     of interdisciplinary training of psychology graduate students 
     for providing behavioral and mental health services, 
     including substance abuse prevention and treatment services;
       ``(3) accredited institutions of higher education or 
     accredited professional training programs that are 
     establishing or expanding internships or other field 
     placement programs in child and adolescent mental health in 
     psychiatry, psychology, school psychology, behavioral 
     pediatrics, psychiatric nursing, social work, school social 
     work, substance abuse prevention and treatment, marriage and 
     family therapy, school counseling, or professional 
     counseling; and
       ``(4) State-licensed mental health nonprofit and for-profit 
     organizations to enable such organizations to pay for 
     programs for preservice or in-service training of 
     paraprofessional child and adolescent mental health workers.
       ``(b) Eligibility Requirements.--To be eligible for a grant 
     under this section, an institution shall demonstrate--
       ``(1) participation in the institutions' programs of 
     individuals and groups from different racial, ethnic, 
     cultural, geographic, religious, linguistic, and class 
     backgrounds, and different genders and sexual orientations;
       ``(2) knowledge and understanding of the concerns of the 
     individuals and groups described in subsection (a);
       ``(3) any internship or other field placement program 
     assisted under the grant will prioritize cultural and 
     linguistic competency;
       ``(4) the institution will provide to the Secretary such 
     data, assurances, and information as the Secretary may 
     require; and
       ``(5) with respect to any violation of the agreement 
     between the Secretary and the institution, the institution 
     will pay such liquidated damages as prescribed by the 
     Secretary by regulation.
       ``(c) Institutional Requirement.--For grants authorized 
     under subsection (a)(1), at least 4 of the grant recipients 
     shall be historically black colleges or universities or other 
     minority-serving institutions.
       ``(d) Priority.--
       ``(1) In selecting the grant recipients in social work 
     under subsection (a)(1), the Secretary shall give priority to 
     applicants that--
       ``(A) are accredited by the Council on Social Work 
     Education;
       ``(B) have a graduation rate of not less than 80 percent 
     for social work students; and
       ``(C) exhibit an ability to recruit social workers from and 
     place social workers in areas with a high need and high 
     demand population.
       ``(2) In selecting the grant recipients in graduate 
     psychology under subsection (a)(2), the Secretary shall give 
     priority to institutions in which training focuses on the 
     needs of vulnerable groups such as older adults and children, 
     individuals with mental health or substance-related 
     disorders, victims of abuse or trauma and of combat stress 
     disorders such as posttraumatic stress disorder and traumatic 
     brain injuries, homeless individuals, chronically ill 
     persons, and their families.
       ``(3) In selecting the grant recipients in training 
     programs in child and adolescent mental health under 
     subsections (a)(3) and (a)(4), the Secretary shall give 
     priority to applicants that--
       ``(A) have demonstrated the ability to collect data on the 
     number of students trained in child and adolescent mental 
     health and the populations served by such students after 
     graduation or completion of preservice or in-service 
     training;
       ``(B) have demonstrated familiarity with evidence-based 
     methods in child and adolescent mental health services, 
     including substance abuse prevention and treatment services;
       ``(C) have programs designed to increase the number of 
     professionals and paraprofessionals serving high-priority 
     populations and to applicants who come from high-priority 
     communities and plan to serve medically underserved 
     populations, in health professional shortage areas, or in 
     medically underserved areas;
       ``(D) offer curriculum taught collaboratively with a family 
     on the consumer and family lived experience or the importance 
     of family-professional or family-paraprofessional 
     partnerships; and
       ``(E) provide services through a community mental health 
     program described in section 1913(b)(1).
       ``(e) Authorization of Appropriation.--For the fiscal years 
     2010 through 2013, there is authorized to be appropriated to 
     carry out this section--
       ``(1) $8,000,000 for training in social work in subsection 
     (a)(1);
       ``(2) $12,000,000 for training in graduate psychology in 
     subsection (a)(2), of which not less than $10,000,000 shall 
     be allocated for doctoral, postdoctoral, and internship level 
     training;
       ``(3) $10,000,000 for training in professional child and 
     adolescent mental health in subsection (a)(3); and
       ``(4) $5,000,000 for training in paraprofessional child and 
     adolescent work in subsection (a)(4).''.
       (b) Conforming Amendments.--Section 757(b)(2) of the Public 
     Health Service Act, as redesignated by subsection (a), is 
     amended by striking ``sections 751(a)(1)(A), 751(a)(1)(B), 
     753(b), 754(3)(A), and 755(b)'' and inserting ``sections 
     751(b)(1)(A), 753(b), and 755(b)''.

     SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC HEALTH 
                   AND INDIVIDUALS WITH DISABILITIES TRAINING.

       (a) Title VII.--Section 741 of the Public Health Service 
     Act (42 U.S.C. 293e) is amended--
       (1) in subsection (a)--
       (A) by striking the subsection heading and inserting 
     ``Cultural Competency, Prevention, and Public Health and 
     Individuals With Disability Grants''; and
       (B) in paragraph (1), by striking ``for the purpose of'' 
     and all that follows through the period at the end and 
     inserting ``for the development, evaluation, and 
     dissemination of research, demonstration projects, and model 
     curricula for cultural competency, prevention, public health 
     proficiency, reducing health disparities, and aptitude for 
     working with individuals with disabilities training for use 
     in health professions schools and continuing education 
     programs, and for other purposes determined as appropriate by 
     the Secretary.''; and
       (2) by striking subsection (b) and inserting the following:
       ``(b) Collaboration.--In carrying out subsection (a), the 
     Secretary shall collaborate with health professional 
     societies, licensing and accreditation entities, health 
     professions schools, and experts in minority health and 
     cultural competency, prevention, and public health and 
     disability groups, community-based organizations, and other 
     organizations as determined appropriate by the Secretary. The 
     Secretary shall coordinate with curricula and research and 
     demonstration projects developed under section 807.
       ``(c) Dissemination.--
       ``(1) In general.--Model curricula developed under this 
     section shall be disseminated through the Internet 
     Clearinghouse under section 270 and such other means as 
     determined appropriate by the Secretary.
       ``(2) Evaluation.--The Secretary shall evaluate the 
     adoption and the implementation of cultural competency, 
     prevention, and public health, and working with individuals 
     with a disability training curricula, and the facilitate 
     inclusion of these competency measures in quality measurement 
     systems as appropriate.
       ``(d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section such sums as may 
     be necessary for each of fiscal years 2010 through 2015.''.
       (b) Title VIII.--Section 807 of the Public Health Service 
     Act (42 U.S.C. 296e-1) is amended--
       (1) in subsection (a)--
       (A) by striking the subsection heading and inserting 
     ``Cultural Competency, Prevention, and Public Health and 
     Individuals With Disability Grants''; and
       (B) by striking ``for the purpose of'' and all that follows 
     through ``health care.'' and inserting ``for the development, 
     evaluation, and dissemination of research, demonstration 
     projects, and model curricula for cultural competency, 
     prevention, public health proficiency, reducing health 
     disparities, and aptitude for working with individuals with 
     disabilities training for use in health professions schools 
     and continuing education programs, and for other purposes 
     determined as appropriate by the Secretary.''; and
       (2) by redesignating subsection (b) as subsection (d);
       (3) by inserting after subsection (a) the following:
       ``(b) Collaboration.--In carrying out subsection (a), the 
     Secretary shall collaborate with the entities described in 
     section 741(b). The Secretary shall coordinate with curricula 
     and research and demonstration projects developed under such 
     section 741.
       ``(c) Dissemination.--Model curricula developed under this 
     section shall be disseminated and evaluated in the same 
     manner as model curricula developed under section 741, as 
     described in subsection (c) of such section.''; and
       (4) in subsection (d), as so redesignated--
       (A) by striking ``subsection (a)'' and inserting ``this 
     section''; and
       (B) by striking ``2001 through 2004'' and inserting ``2010 
     through 2015''.

     SEC. 5308. ADVANCED NURSING EDUCATION GRANTS.

       Section 811 of the Public Health Service Act (42 U.S.C. 
     296j) is amended--
       (1) in subsection (c)--
       (A) in the subsection heading, by striking ``and Nurse 
     Midwifery Programs''; and
       (B) by striking ``and nurse midwifery'';
       (2) in subsection (f)--
       (A) by striking paragraph (2); and
       (B) by redesignating paragraph (3) as paragraph (2); and
       (3) by redesignating subsections (d), (e), and (f) as 
     subsections (e), (f), and (g), respectively; and
       (4) by inserting after subsection (c), the following:
       ``(d) Authorized Nurse-midwifery Programs.--Midwifery 
     programs that are eligible for support under this section are 
     educational programs that--
       ``(1) have as their objective the education of midwives; 
     and
       ``(2) are accredited by the American College of Nurse-
     Midwives Accreditation Commission for Midwifery Education.''.

     SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS.

       (a) In General.--Section 831 of the Public Health Service 
     Act (42 U.S.C. 296p) is amended--
       (1) in the section heading, by striking ``RETENTION'' and 
     inserting ``QUALITY'';
       (2) in subsection (a)--
       (A) in paragraph (1), by adding ``or'' after the semicolon;
       (B) by striking paragraph (2); and
       (C) by redesignating paragraph (3) as paragraph (2);
       (3) in subsection (b)(3), by striking ``managed care, 
     quality improvement'' and inserting ``coordinated care'';
       (4) in subsection (g), by inserting ``, as defined in 
     section 801(2),'' after ``school of nursing''; and

[[Page 4340]]

       (5) in subsection (h), by striking ``2003 through 2007'' 
     and inserting ``2010 through 2014''.
       (b) Nurse Retention Grants.--Title VIII of the Public 
     Health Service Act is amended by inserting after section 831 
     (42 U.S.C. 296b) the following:

     ``SEC. 831A. NURSE RETENTION GRANTS.

       ``(a) Retention Priority Areas.--The Secretary may award 
     grants to, and enter into contracts with, eligible entities 
     to enhance the nursing workforce by initiating and 
     maintaining nurse retention programs pursuant to subsection 
     (b) or (c).
       ``(b) Grants for Career Ladder Program.--The Secretary may 
     award grants to, and enter into contracts with, eligible 
     entities for programs--
       ``(1) to promote career advancement for individuals 
     including licensed practical nurses, licensed vocational 
     nurses, certified nurse assistants, home health aides, 
     diploma degree or associate degree nurses, to become 
     baccalaureate prepared registered nurses or advanced 
     education nurses in order to meet the needs of the registered 
     nurse workforce;
       ``(2) developing and implementing internships and residency 
     programs in collaboration with an accredited school of 
     nursing, as defined by section 801(2), to encourage mentoring 
     and the development of specialties; or
       ``(3) to assist individuals in obtaining education and 
     training required to enter the nursing profession and advance 
     within such profession.
       ``(c) Enhancing Patient Care Delivery Systems.--
       ``(1) Grants.--The Secretary may award grants to eligible 
     entities to improve the retention of nurses and enhance 
     patient care that is directly related to nursing activities 
     by enhancing collaboration and communication among nurses and 
     other health care professionals, and by promoting nurse 
     involvement in the organizational and clinical decision-
     making processes of a health care facility.
       ``(2) Priority.--In making awards of grants under this 
     subsection, the Secretary shall give preference to applicants 
     that have not previously received an award under this 
     subsection (or section 831(c) as such section existed on the 
     day before the date of enactment of this section).
       ``(3) Continuation of an award.--The Secretary shall make 
     continuation of any award under this subsection beyond the 
     second year of such award contingent on the recipient of such 
     award having demonstrated to the Secretary measurable and 
     substantive improvement in nurse retention or patient care.
       ``(d) Other Priority Areas.--The Secretary may award grants 
     to, or enter into contracts with, eligible entities to 
     address other areas that are of high priority to nurse 
     retention, as determined by the Secretary.
       ``(e) Report.--The Secretary shall submit to the Congress 
     before the end of each fiscal year a report on the grants 
     awarded and the contracts entered into under this section. 
     Each such report shall identify the overall number of such 
     grants and contracts and provide an explanation of why each 
     such grant or contract will meet the priority need of the 
     nursing workforce.
       ``(f) Eligible Entity.--For purposes of this section, the 
     term `eligible entity' includes an accredited school of 
     nursing, as defined by section 801(2), a health care 
     facility, or a partnership of such a school and facility.
       ``(g) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section such 
     sums as may be necessary for each of fiscal years 2010 
     through 2012.''.

     SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM.

       (a) Loan Repayments and Scholarships.--Section 846(a)(3) of 
     the Public Health Service Act (42 U.S.C. 297n(a)(3)) is 
     amended by inserting before the semicolon the following: ``, 
     or in a accredited school of nursing, as defined by section 
     801(2), as nurse faculty''.
       (b) Technical and Conforming Amendments.--Title VIII (42 
     U.S.C. 296 et seq.) is amended--
       (1) by redesignating section 810 (relating to prohibition 
     against discrimination by schools on the basis of sex) as 
     section 809 and moving such section so that it follows 
     section 808;
       (2) in sections 835, 836, 838, 840, and 842, by striking 
     the term ``this subpart'' each place it appears and inserting 
     ``this part'';
       (3) in section 836(h), by striking the last sentence;
       (4) in section 836, by redesignating subsection (l) as 
     subsection (k);
       (5) in section 839, by striking ``839'' and all that 
     follows through ``(a)'' and inserting ``839. (a)'';
       (6) in section 835(b), by striking ``841'' each place it 
     appears and inserting ``871'';
       (7) by redesignating section 841 as section 871, moving 
     part F to the end of the title, and redesignating such part 
     as part I;
       (8) in part G--
       (A) by redesignating section 845 as section 851; and
       (B) by redesignating part G as part F;
       (9) in part H--
       (A) by redesignating sections 851 and 852 as sections 861 
     and 862, respectively; and
       (B) by redesignating part H as part G; and
       (10) in part I--
       (A) by redesignating section 855, as amended by section 
     5305, as section 865; and
       (B) by redesignating part I as part H.

     SEC. 5311. NURSE FACULTY LOAN PROGRAM.

       (a) In General.--Section 846A of the Public Health Service 
     Act (42 U.S.C. 297n-1) is amended--
       (1) in subsection (a)--
       (A) in the subsection heading, by striking 
     ``Establishment'' and inserting ``School of Nursing Student 
     Loan Fund''; and
       (B) by inserting ``accredited'' after ``agreement with 
     any'';
       (2) in subsection (c)--
       (A) in paragraph (2), by striking ``$30,000'' and all that 
     follows through the semicolon and inserting ``$35,500, during 
     fiscal years 2010 and 2011 fiscal years (after fiscal year 
     2011, such amounts shall be adjusted to provide for a cost-
     of-attendance increase for the yearly loan rate and the 
     aggregate loan;''; and
       (B) in paragraph (3)(A), by inserting ``an accredited'' 
     after ``faculty member in'';
       (3) in subsection (e), by striking ``a school'' and 
     inserting ``an accredited school''; and
       (4) in subsection (f), by striking ``2003 through 2007'' 
     and inserting ``2010 through 2014''.
       (b) Eligible Individual Student Loan Repayment.--Title VIII 
     of the Public Health Service Act is amended by inserting 
     after section 846A (42 U.S.C. 297n-1) the following:

     ``SEC. 847. ELIGIBLE INDIVIDUAL STUDENT LOAN REPAYMENT.

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, may enter into an agreement with eligible 
     individuals for the repayment of education loans, in 
     accordance with this section, to increase the number of 
     qualified nursing faculty.
       ``(b) Agreements.--Each agreement entered into under this 
     subsection shall require that the eligible individual shall 
     serve as a full-time member of the faculty of an accredited 
     school of nursing, for a total period, in the aggregate, of 
     at least 4 years during the 6-year period beginning on the 
     later of--
       ``(1) the date on which the individual receives a master's 
     or doctorate nursing degree from an accredited school of 
     nursing; or
       ``(2) the date on which the individual enters into an 
     agreement under this subsection.
       ``(c) Agreement Provisions.--Agreements entered into 
     pursuant to subsection (b) shall be entered into on such 
     terms and conditions as the Secretary may determine, except 
     that--
       ``(1) not more than 10 months after the date on which the 
     6-year period described under subsection (b) begins, but in 
     no case before the individual starts as a full-time member of 
     the faculty of an accredited school of nursing the Secretary 
     shall begin making payments, for and on behalf of that 
     individual, on the outstanding principal of, and interest on, 
     any loan of that individual obtained to pay for such degree;
       ``(2) for an individual who has completed a master's in 
     nursing or equivalent degree in nursing--
       ``(A) payments may not exceed $10,000 per calendar year; 
     and
       ``(B) total payments may not exceed $40,000 during the 2010 
     and 2011 fiscal years (after fiscal year 2011, such amounts 
     shall be adjusted to provide for a cost-of-attendance 
     increase for the yearly loan rate and the aggregate loan); 
     and
       ``(3) for an individual who has completed a doctorate or 
     equivalent degree in nursing--
       ``(A) payments may not exceed $20,000 per calendar year; 
     and
       ``(B) total payments may not exceed $80,000 during the 2010 
     and 2011 fiscal years (adjusted for subsequent fiscal years 
     as provided for in the same manner as in paragraph (2)(B)).
       ``(d) Breach of Agreement.--
       ``(1) In general.--In the case of any agreement made under 
     subsection (b), the individual is liable to the Federal 
     Government for the total amount paid by the Secretary under 
     such agreement, and for interest on such amount at the 
     maximum legal prevailing rate, if the individual fails to 
     meet the agreement terms required under such subsection.
       ``(2) Waiver or suspension of liability.--In the case of an 
     individual making an agreement for purposes of paragraph (1), 
     the Secretary shall provide for the waiver or suspension of 
     liability under such paragraph if compliance by the 
     individual with the agreement involved is impossible or would 
     involve extreme hardship to the individual or if enforcement 
     of the agreement with respect to the individual would be 
     unconscionable.
       ``(3) Date certain for recovery.--Subject to paragraph (2), 
     any amount that the Federal Government is entitled to recover 
     under paragraph (1) shall be paid to the United States not 
     later than the expiration of the 3-year period beginning on 
     the date the United States becomes so entitled.
       ``(4) Availability.--Amounts recovered under paragraph (1) 
     shall be available to the Secretary for making loan 
     repayments under this section and shall remain available for 
     such purpose until expended.
       ``(e) Eligible Individual Defined.--For purposes of this 
     section, the term `eligible individual' means an individual 
     who--
       ``(1) is a United States citizen, national, or lawful 
     permanent resident;
       ``(2) holds an unencumbered license as a registered nurse; 
     and
       ``(3) has either already completed a master's or doctorate 
     nursing program at an accredited school of nursing or is 
     currently enrolled on a full-time or part-time basis in such 
     a program.
       ``(f) Priority.--For the purposes of this section and 
     section 846A, funding priority will be awarded to School of 
     Nursing Student Loans that support doctoral nursing students 
     or Individual Student Loan Repayment that support doctoral 
     nursing students.
       ``(g) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section such 
     sums as may be necessary for each of fiscal years 2010 
     through 2014.''.

[[Page 4341]]



     SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B 
                   THROUGH D OF TITLE VIII.

       Section 871 of the Public Health Service Act, as 
     redesignated and moved by section 5310, is amended to read as 
     follows:

     ``SEC. 871. AUTHORIZATION OF APPROPRIATIONS.

       ``For the purpose of carrying out parts B, C, and D 
     (subject to section 851(g)), there are authorized to be 
     appropriated $338,000,000 for fiscal year 2010, and such sums 
     as may be necessary for each of the fiscal years 2011 through 
     2016.''.

     SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH WORKFORCE.

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

     ``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND 
                   OUTCOMES.

       ``(a) Grants Authorized.--The Director of the Centers for 
     Disease Control and Prevention, in collaboration with the 
     Secretary, shall award grants to eligible entities to promote 
     positive health behaviors and outcomes for populations in 
     medically underserved communities through the use of 
     community health workers.
       ``(b) Use of Funds.--Grants awarded under subsection (a) 
     shall be used to support community health workers--
       ``(1) to educate, guide, and provide outreach in a 
     community setting regarding health problems prevalent in 
     medically underserved communities, particularly racial and 
     ethnic minority populations;
       ``(2) to educate and provide guidance regarding effective 
     strategies to promote positive health behaviors and 
     discourage risky health behaviors;
       ``(3) to educate and provide outreach regarding enrollment 
     in health insurance including the Children's Health Insurance 
     Program under title XXI of the Social Security Act, Medicare 
     under title XVIII of such Act and Medicaid under title XIX of 
     such Act;
       ``(4) to identify, educate, refer, and enroll underserved 
     populations to appropriate healthcare agencies and community-
     based programs and organizations in order to increase access 
     to quality healthcare services and to eliminate duplicative 
     care; or
       ``(5) to educate, guide, and provide home visitation 
     services regarding maternal health and prenatal care.
       ``(c) Application.--Each eligible entity that desires to 
     receive a grant under subsection (a) shall submit an 
     application to the Secretary, at such time, in such manner, 
     and accompanied by such information as the Secretary may 
     require.
       ``(d) Priority.--In awarding grants under subsection (a), 
     the Secretary shall give priority to applicants that--
       ``(1) propose to target geographic areas--
       ``(A) with a high percentage of residents who are eligible 
     for health insurance but are uninsured or underinsured;
       ``(B) with a high percentage of residents who suffer from 
     chronic diseases; or
       ``(C) with a high infant mortality rate;
       ``(2) have experience in providing health or health-related 
     social services to individuals who are underserved with 
     respect to such services; and
       ``(3) have documented community activity and experience 
     with community health workers.
       ``(e) Collaboration With Academic Institutions and the One-
     stop Delivery System.--The Secretary shall encourage 
     community health worker programs receiving funds under this 
     section to collaborate with academic institutions and one-
     stop delivery systems under section 134(c) of the Workforce 
     Investment Act of 1998. Nothing in this section shall be 
     construed to require such collaboration.
       ``(f) Evidence-based Interventions.--The Secretary shall 
     encourage community health worker programs receiving funding 
     under this section to implement a process or an outcome-based 
     payment system that rewards community health workers for 
     connecting underserved populations with the most appropriate 
     services at the most appropriate time. Nothing in this 
     section shall be construed to require such a payment.
       ``(g) Quality Assurance and Cost Effectiveness.--The 
     Secretary shall establish guidelines for assuring the quality 
     of the training and supervision of community health workers 
     under the programs funded under this section and for assuring 
     the cost-effectiveness of such programs.
       ``(h) Monitoring.--The Secretary shall monitor community 
     health worker programs identified in approved applications 
     under this section and shall determine whether such programs 
     are in compliance with the guidelines established under 
     subsection (g).
       ``(i) Technical Assistance.--The Secretary may provide 
     technical assistance to community health worker programs 
     identified in approved applications under this section with 
     respect to planning, developing, and operating programs under 
     the grant.
       ``(j) Authorization of Appropriations.--There are 
     authorized to be appropriated, such sums as may be necessary 
     to carry out this section for each of fiscal years 2010 
     through 2014.
       ``(k) Definitions.--In this section:
       ``(1) Community health worker.--The term `community health 
     worker', as defined by the Department of Labor as Standard 
     Occupational Classification [21-1094] means an individual who 
     promotes health or nutrition within the community in which 
     the individual resides--
       ``(A) by serving as a liaison between communities and 
     healthcare agencies;
       ``(B) by providing guidance and social assistance to 
     community residents;
       ``(C) by enhancing community residents' ability to 
     effectively communicate with healthcare providers;
       ``(D) by providing culturally and linguistically 
     appropriate health or nutrition education;
       ``(E) by advocating for individual and community health;
       ``(F) by providing referral and follow-up services or 
     otherwise coordinating care; and
       ``(G) by proactively identifying and enrolling eligible 
     individuals in Federal, State, local, private or nonprofit 
     health and human services programs.
       ``(2) Community setting.--The term `community setting' 
     means a home or a community organization located in the 
     neighborhood in which a participant in the program under this 
     section resides.
       ``(3) Eligible entity.--The term `eligible entity' means a 
     public or nonprofit private entity (including a State or 
     public subdivision of a State, a public health department, a 
     free health clinic, a hospital, or a Federally-qualified 
     health center (as defined in section 1861(aa) of the Social 
     Security Act)), or a consortium of any such entities.
       ``(4) Medically underserved community.--The term `medically 
     underserved community' means a community identified by a 
     State--
       ``(A) that has a substantial number of individuals who are 
     members of a medically underserved population, as defined by 
     section 330(b)(3); and
       ``(B) a significant portion of which is a health 
     professional shortage area as designated under section 
     332.''.

     SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH.

       Part E of title VII of the Public Health Service Act (42 
     U.S.C. 294n et seq.), as amended by section 5206, is further 
     amended by adding at the end the following:

     ``SEC. 778. FELLOWSHIP TRAINING IN APPLIED PUBLIC HEALTH 
                   EPIDEMIOLOGY, PUBLIC HEALTH LABORATORY SCIENCE, 
                   PUBLIC HEALTH INFORMATICS, AND EXPANSION OF THE 
                   EPIDEMIC INTELLIGENCE SERVICE.

       ``(a) In General.--The Secretary may carry out activities 
     to address documented workforce shortages in State and local 
     health departments in the critical areas of applied public 
     health epidemiology and public health laboratory science and 
     informatics and may expand the Epidemic Intelligence Service.
       ``(b) Specific Uses.--In carrying out subsection (a), the 
     Secretary shall provide for the expansion of existing 
     fellowship programs operated through the Centers for Disease 
     Control and Prevention in a manner that is designed to 
     alleviate shortages of the type described in subsection (a).
       ``(c) Other Programs.--The Secretary may provide for the 
     expansion of other applied epidemiology training programs 
     that meet objectives similar to the objectives of the 
     programs described in subsection (b).
       ``(d) Work Obligation.--Participation in fellowship 
     training programs under this section shall be deemed to be 
     service for purposes of satisfying work obligations 
     stipulated in contracts under section 338I(j).
       ``(e) General Support.--Amounts may be used from grants 
     awarded under this section to expand the Public Health 
     Informatics Fellowship Program at the Centers for Disease 
     Control and Prevention to better support all public health 
     systems at all levels of government.
       ``(f) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section 
     $39,500,000 for each of fiscal years 2010 through 2013, of 
     which--
       ``(1) $5,000,000 shall be made available in each such 
     fiscal year for epidemiology fellowship training program 
     activities under subsections (b) and (c);
       ``(2) $5,000,000 shall be made available in each such 
     fiscal year for laboratory fellowship training programs under 
     subsection (b);
       ``(3) $5,000,000 shall be made available in each such 
     fiscal year for the Public Health Informatics Fellowship 
     Program under subsection (e); and
       ``(4) $24,500,000 shall be made available for expanding the 
     Epidemic Intelligence Service under subsection (a).''.

     SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK.

       Title II of the Public Health Service Act (42 U.S.C. 202 et 
     seq.) is amended by adding at the end the following:

          ``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK

     ``SEC. 271. ESTABLISHMENT.

       ``(a) United States Public Health Services Track.--
       ``(1) In general.--There is hereby authorized to be 
     established a United States Public Health Sciences Track 
     (referred to in this part as the `Track'), at sites to be 
     selected by the Secretary, with authority to grant 
     appropriate advanced degrees in a manner that uniquely 
     emphasizes team-based service, public health, epidemiology, 
     and emergency preparedness and response. It shall be so 
     organized as to graduate not less than--
       ``(A) 150 medical students annually, 10 of whom shall be 
     awarded studentships to the Uniformed Services University of 
     Health Sciences;
       ``(B) 100 dental students annually;
       ``(C) 250 nursing students annually;
       ``(D) 100 public health students annually;
       ``(E) 100 behavioral and mental health professional 
     students annually;

[[Page 4342]]

       ``(F) 100 physician assistant or nurse practitioner 
     students annually; and
       ``(G) 50 pharmacy students annually.
       ``(2) Locations.--The Track shall be located at existing 
     and accredited, affiliated health professions education 
     training programs at academic health centers located in 
     regions of the United States determined appropriate by the 
     Surgeon General, in consultation with the National Health 
     Care Workforce Commission established in section 5101 of the 
     Patient Protection and Affordable Care Act.
       ``(b) Number of Graduates.--Except as provided in 
     subsection (a), the number of persons to be graduated from 
     the Track shall be prescribed by the Secretary. In so 
     prescribing the number of persons to be graduated from the 
     Track, the Secretary shall institute actions necessary to 
     ensure the maximum number of first-year enrollments in the 
     Track consistent with the academic capacity of the affiliated 
     sites and the needs of the United States for medical, dental, 
     and nursing personnel.
       ``(c) Development.--The development of the Track may be by 
     such phases as the Secretary may prescribe subject to the 
     requirements of subsection (a).
       ``(d) Integrated Longitudinal Plan.--The Surgeon General 
     shall develop an integrated longitudinal plan for health 
     professions continuing education throughout the continuum of 
     health-related education, training, and practice. Training 
     under such plan shall emphasize patient-centered, 
     interdisciplinary, and care coordination skills. Experience 
     with deployment of emergency response teams shall be included 
     during the clinical experiences.
       ``(e) Faculty Development.--The Surgeon General shall 
     develop faculty development programs and curricula in 
     decentralized venues of health care, to balance urban, 
     tertiary, and inpatient venues.

     ``SEC. 272. ADMINISTRATION.

       ``(a) In General.--The business of the Track shall be 
     conducted by the Surgeon General with funds appropriated for 
     and provided by the Department of Health and Human Services. 
     The National Health Care Workforce Commission shall assist 
     the Surgeon General in an advisory capacity.
       ``(b) Faculty.--
       ``(1) In general.--The Surgeon General, after considering 
     the recommendations of the National Health Care Workforce 
     Commission, shall obtain the services of such professors, 
     instructors, and administrative and other employees as may be 
     necessary to operate the Track, but utilize when possible, 
     existing affiliated health professions training institutions. 
     Members of the faculty and staff shall be employed under 
     salary schedules and granted retirement and other related 
     benefits prescribed by the Secretary so as to place the 
     employees of the Track faculty on a comparable basis with the 
     employees of fully accredited schools of the health 
     professions within the United States.
       ``(2) Titles.--The Surgeon General may confer academic 
     titles, as appropriate, upon the members of the faculty.
       ``(3) Nonapplication of provisions.--The limitations in 
     section 5373 of title 5, United States Code, shall not apply 
     to the authority of the Surgeon General under paragraph (1) 
     to prescribe salary schedules and other related benefits.
       ``(c) Agreements.--The Surgeon General may negotiate 
     agreements with agencies of the Federal Government to utilize 
     on a reimbursable basis appropriate existing Federal medical 
     resources located in the United States (or locations selected 
     in accordance with section 271(a)(2)). Under such agreements 
     the facilities concerned will retain their identities and 
     basic missions. The Surgeon General may negotiate affiliation 
     agreements with accredited universities and health 
     professions training institutions in the United States. Such 
     agreements may include provisions for payments for 
     educational services provided students participating in 
     Department of Health and Human Services educational programs.
       ``(d) Programs.--The Surgeon General may establish the 
     following educational programs for Track students:
       ``(1) Postdoctoral, postgraduate, and technological 
     programs.
       ``(2) A cooperative program for medical, dental, physician 
     assistant, pharmacy, behavioral and mental health, public 
     health, and nursing students.
       ``(3) Other programs that the Surgeon General determines 
     necessary in order to operate the Track in a cost-effective 
     manner.
       ``(e) Continuing Medical Education.--The Surgeon General 
     shall establish programs in continuing medical education for 
     members of the health professions to the end that high 
     standards of health care may be maintained within the United 
     States.
       ``(f) Authority of the Surgeon General.--
       ``(1) In general.--The Surgeon General is authorized--
       ``(A) to enter into contracts with, accept grants from, and 
     make grants to any nonprofit entity for the purpose of 
     carrying out cooperative enterprises in medical, dental, 
     physician assistant, pharmacy, behavioral and mental health, 
     public health, and nursing research, consultation, and 
     education;
       ``(B) to enter into contracts with entities under which the 
     Surgeon General may furnish the services of such 
     professional, technical, or clerical personnel as may be 
     necessary to fulfill cooperative enterprises undertaken by 
     the Track;
       ``(C) to accept, hold, administer, invest, and spend any 
     gift, devise, or bequest of personal property made to the 
     Track, including any gift, devise, or bequest for the support 
     of an academic chair, teaching, research, or demonstration 
     project;
       ``(D) to enter into agreements with entities that may be 
     utilized by the Track for the purpose of enhancing the 
     activities of the Track in education, research, and 
     technological applications of knowledge; and
       ``(E) to accept the voluntary services of guest scholars 
     and other persons.
       ``(2) Limitation.--The Surgeon General may not enter into 
     any contract with an entity if the contract would obligate 
     the Track to make outlays in advance of the enactment of 
     budget authority for such outlays.
       ``(3) Scientists.--Scientists or other medical, dental, or 
     nursing personnel utilized by the Track under an agreement 
     described in paragraph (1) may be appointed to any position 
     within the Track and may be permitted to perform such duties 
     within the Track as the Surgeon General may approve.
       ``(4) Volunteer services.--A person who provides voluntary 
     services under the authority of subparagraph (E) of paragraph 
     (1) shall be considered to be an employee of the Federal 
     Government for the purposes of chapter 81 of title 5, 
     relating to compensation for work-related injuries, and to be 
     an employee of the Federal Government for the purposes of 
     chapter 171 of title 28, relating to tort claims. Such a 
     person who is not otherwise employed by the Federal 
     Government shall not be considered to be a Federal employee 
     for any other purpose by reason of the provision of such 
     services.

     ``SEC. 273. STUDENTS; SELECTION; OBLIGATION.

       ``(a) Student Selection.--
       ``(1) In general.--Medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, and 
     nursing students at the Track shall be selected under 
     procedures prescribed by the Surgeon General. In so 
     prescribing, the Surgeon General shall consider the 
     recommendations of the National Health Care Workforce 
     Commission.
       ``(2) Priority.--In developing admissions procedures under 
     paragraph (1), the Surgeon General shall ensure that such 
     procedures give priority to applicant medical, dental, 
     physician assistant, pharmacy, behavioral and mental health, 
     public health, and nursing students from rural communities 
     and underrepresented minorities.
       ``(b) Contract and Service Obligation.--
       ``(1) Contract.--Upon being admitted to the Track, a 
     medical, dental, physician assistant, pharmacy, behavioral 
     and mental health, public health, or nursing student shall 
     enter into a written contract with the Surgeon General that 
     shall contain--
       ``(A) an agreement under which--
       ``(i) subject to subparagraph (B), the Surgeon General 
     agrees to provide the student with tuition (or tuition 
     remission) and a student stipend (described in paragraph (2)) 
     in each school year for a period of years (not to exceed 4 
     school years) determined by the student, during which period 
     the student is enrolled in the Track at an affiliated or 
     other participating health professions institution pursuant 
     to an agreement between the Track and such institution; and
       ``(ii) subject to subparagraph (B), the student agrees--

       ``(I) to accept the provision of such tuition and student 
     stipend to the student;
       ``(II) to maintain enrollment at the Track until the 
     student completes the course of study involved;
       ``(III) while enrolled in such course of study, to maintain 
     an acceptable level of academic standing (as determined by 
     the Surgeon General);
       ``(IV) if pursuing a degree from a school of medicine or 
     osteopathic medicine, dental, public health, or nursing 
     school or a physician assistant, pharmacy, or behavioral and 
     mental health professional program, to complete a residency 
     or internship in a specialty that the Surgeon General 
     determines is appropriate; and
       ``(V) to serve for a period of time (referred to in this 
     part as the `period of obligated service') within the 
     Commissioned Corps of the Public Health Service equal to 2 
     years for each school year during which such individual was 
     enrolled at the College, reduced as provided for in paragraph 
     (3);

       ``(B) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this part and any obligation of the student which is 
     conditioned thereon, is contingent upon funds being 
     appropriated to carry out this part;
       ``(C) a statement of the damages to which the United States 
     is entitled for the student's breach of the contract; and
       ``(D) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     the provisions of this part.
       ``(2) Tuition and student stipend.--
       ``(A) Tuition remission rates.--The Surgeon General, based 
     on the recommendations of the National Health Care Workforce 
     Commission, shall establish Federal tuition remission rates 
     to be used by the Track to provide reimbursement to 
     affiliated and other participating health professions 
     institutions for the cost of educational services provided by 
     such institutions to Track students. The agreement entered 
     into by such participating institutions under paragraph 
     (1)(A)(i) shall contain an agreement to accept as payment in 
     full the established remission rate under this subparagraph.
       ``(B) Stipend.--The Surgeon General, based on the 
     recommendations of the National Health

[[Page 4343]]

     Care Workforce Commission, shall establish and update Federal 
     stipend rates for payment to students under this part.
       ``(3) Reductions in the period of obligated service.--The 
     period of obligated service under paragraph (1)(A)(ii)(V) 
     shall be reduced--
       ``(A) in the case of a student who elects to participate in 
     a high-needs speciality residency (as determined by the 
     National Health Care Workforce Commission), by 3 months for 
     each year of such participation (not to exceed a total of 12 
     months); and
       ``(B) in the case of a student who, upon completion of 
     their residency, elects to practice in a Federal medical 
     facility (as defined in section 781(e)) that is located in a 
     health professional shortage area (as defined in section 
     332), by 3 months for year of full-time practice in such a 
     facility (not to exceed a total of 12 months).
       ``(c) Second 2 Years of Service.--During the third and 
     fourth years in which a medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, or 
     nursing student is enrolled in the Track, training should be 
     designed to prioritize clinical rotations in Federal medical 
     facilities in health professional shortage areas, and 
     emphasize a balance of hospital and community-based 
     experiences, and training within interdisciplinary teams.
       ``(d) Dentist, Physician Assistant, Pharmacist, Behavioral 
     and Mental Health Professional, Public Health Professional, 
     and Nurse Training.--The Surgeon General shall establish 
     provisions applicable with respect to dental, physician 
     assistant, pharmacy, behavioral and mental health, public 
     health, and nursing students that are comparable to those for 
     medical students under this section, including service 
     obligations, tuition support, and stipend support. The 
     Surgeon General shall give priority to health professions 
     training institutions that train medical, dental, physician 
     assistant, pharmacy, behavioral and mental health, public 
     health, and nursing students for some significant period of 
     time together, but at a minimum have a discrete and shared 
     core curriculum.
       ``(e) Elite Federal Disaster Teams.--The Surgeon General, 
     in consultation with the Secretary, the Director of the 
     Centers for Disease Control and Prevention, and other 
     appropriate military and Federal government agencies, shall 
     develop criteria for the appointment of highly qualified 
     Track faculty, medical, dental, physician assistant, 
     pharmacy, behavioral and mental health, public health, and 
     nursing students, and graduates to elite Federal disaster 
     preparedness teams to train and to respond to public health 
     emergencies, natural disasters, bioterrorism events, and 
     other emergencies.
       ``(f) Student Dropped From Track in Affiliate School.--A 
     medical, dental, physician assistant, pharmacy, behavioral 
     and mental health, public health, or nursing student who, 
     under regulations prescribed by the Surgeon General, is 
     dropped from the Track in an affiliated school for deficiency 
     in conduct or studies, or for other reasons, shall be liable 
     to the United States for all tuition and stipend support 
     provided to the student.

     ``SEC. 274. FUNDING.

       ``Beginning with fiscal year 2010, the Secretary shall 
     transfer from the Public Health and Social Services Emergency 
     Fund such sums as may be necessary to carry out this part.''.

       Subtitle E--Supporting the Existing Health Care Workforce

     SEC. 5401. CENTERS OF EXCELLENCE.

       Section 736 of the Public Health Service Act (42 U.S.C. 
     293) is amended by striking subsection (h) and inserting the 
     following:
       ``(h) Formula for Allocations.--
       ``(1) Allocations.--Based on the amount appropriated under 
     subsection (i) for a fiscal year, the following subparagraphs 
     shall apply as appropriate:
       ``(A) In general.--If the amounts appropriated under 
     subsection (i) for a fiscal year are $24,000,000 or less--
       ``(i) the Secretary shall make available $12,000,000 for 
     grants under subsection (a) to health professions schools 
     that meet the conditions described in subsection (c)(2)(A); 
     and
       ``(ii) and available after grants are made with funds under 
     clause (i), the Secretary shall make available--

       ``(I) 60 percent of such amount for grants under subsection 
     (a) to health professions schools that meet the conditions 
     described in paragraph (3) or (4) of subsection (c) 
     (including meeting the conditions under subsection (e)); and
       ``(II) 40 percent of such amount for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in subsection (c)(5).

       ``(B) Funding in excess of $24,000,000.--If amounts 
     appropriated under subsection (i) for a fiscal year exceed 
     $24,000,000 but are less than $30,000,000--
       ``(i) 80 percent of such excess amounts shall be made 
     available for grants under subsection (a) to health 
     professions schools that meet the requirements described in 
     paragraph (3) or (4) of subsection (c) (including meeting 
     conditions pursuant to subsection (e)); and
       ``(ii) 20 percent of such excess amount shall be made 
     available for grants under subsection (a) to health 
     professions schools that meet the conditions described in 
     subsection (c)(5).
       ``(C) Funding in excess of $30,000,000.--If amounts 
     appropriated under subsection (i) for a fiscal year exceed 
     $30,000,000 but are less than $40,000,000, the Secretary 
     shall make available--
       ``(i) not less than $12,000,000 for grants under subsection 
     (a) to health professions schools that meet the conditions 
     described in subsection (c)(2)(A);
       ``(ii) not less than $12,000,000 for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in paragraph (3) or (4) of subsection 
     (c) (including meeting conditions pursuant to subsection 
     (e));
       ``(iii) not less than $6,000,000 for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in subsection (c)(5); and
       ``(iv) after grants are made with funds under clauses (i) 
     through (iii), any remaining excess amount for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in paragraph (2)(A), (3), (4), or (5) of 
     subsection (c).
       ``(D) Funding in excess of $40,000,000.--If amounts 
     appropriated under subsection (i) for a fiscal year are 
     $40,000,000 or more, the Secretary shall make available--
       ``(i) not less than $16,000,000 for grants under subsection 
     (a) to health professions schools that meet the conditions 
     described in subsection (c)(2)(A);
       ``(ii) not less than $16,000,000 for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in paragraph (3) or (4) of subsection 
     (c) (including meeting conditions pursuant to subsection 
     (e));
       ``(iii) not less than $8,000,000 for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in subsection (c)(5); and
       ``(iv) after grants are made with funds under clauses (i) 
     through (iii), any remaining funds for grants under 
     subsection (a) to health professions schools that meet the 
     conditions described in paragraph (2)(A), (3), (4), or (5) of 
     subsection (c).
       ``(2) No limitation.--Nothing in this subsection shall be 
     construed as limiting the centers of excellence referred to 
     in this section to the designated amount, or to preclude such 
     entities from competing for grants under this section.
       ``(3) Maintenance of effort.--
       ``(A) In general.--With respect to activities for which a 
     grant made under this part are authorized to be expended, the 
     Secretary may not make such a grant to a center of excellence 
     for any fiscal year unless the center agrees to maintain 
     expenditures of non-Federal amounts for such activities at a 
     level that is not less than the level of such expenditures 
     maintained by the center for the fiscal year preceding the 
     fiscal year for which the school receives such a grant.
       ``(B) Use of federal funds.--With respect to any Federal 
     amounts received by a center of excellence and available for 
     carrying out activities for which a grant under this part is 
     authorized to be expended, the center shall, before expending 
     the grant, expend the Federal amounts obtained from sources 
     other than the grant, unless given prior approval from the 
     Secretary.
       ``(i) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section--
       ``(1) $50,000,000 for each of the fiscal years 2010 through 
     2015; and
       ``(2) and such sums as are necessary for each subsequent 
     fiscal year.''.

     SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY.

       (a) Loan Repayments and Fellowships Regarding Faculty 
     Positions.--Section 738(a)(1) of the Public Health Service 
     Act (42 U.S.C. 293b(a)(1)) is amended by striking ``$20,000 
     of the principal and interest of the educational loans of 
     such individuals.'' and inserting ``$30,000 of the principal 
     and interest of the educational loans of such individuals.''.
       (b) Scholarships for Disadvantaged Students.--Section 
     740(a) of such Act (42 U.S.C. 293d(a)) is amended by striking 
     ``$37,000,000'' and all that follows through ``2002'' and 
     inserting ``$51,000,000 for fiscal year 2010, and such sums 
     as may be necessary for each of the fiscal years 2011 through 
     2014''.
       (c) Reauthorization for Loan Repayments and Fellowships 
     Regarding Faculty Positions.--Section 740(b) of such Act (42 
     U.S.C. 293d(b)) is amended by striking ``appropriated'' and 
     all that follows through the period at the end and inserting 
     ``appropriated, $5,000,000 for each of the fiscal years 2010 
     through 2014.''.
       (d) Reauthorization for Educational Assistance in the 
     Health Professions Regarding Individuals From a Disadvantaged 
     Background.--Section 740(c) of such Act (42 U.S.C. 293d(c)) 
     is amended by striking the first sentence and inserting the 
     following: ``For the purpose of grants and contracts under 
     section 739(a)(1), there is authorized to be appropriated 
     $60,000,000 for fiscal year 2010 and such sums as may be 
     necessary for each of the fiscal years 2011 through 2014.''

     SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES.

       (a) Area Health Education Centers.--Section 751 of the 
     Public Health Service Act (42 U.S.C. 294a) is amended to read 
     as follows:

     ``SEC. 751. AREA HEALTH EDUCATION CENTERS.

       ``(a) Establishment of Awards.--The Secretary shall make 
     the following 2 types of awards in accordance with this 
     section:
       ``(1) Infrastructure development award.--The Secretary 
     shall make awards to eligible entities to enable such 
     entities to initiate health care workforce educational 
     programs or to continue to carry out comparable programs that 
     are operating at the time the award is made by planning, 
     developing, operating, and evaluating an area health 
     education center program.
       ``(2) Point of service maintenance and enhancement award.--
     The Secretary shall make awards to eligible entities to 
     maintain and improve the effectiveness and capabilities of an 
     existing area health education center program,

[[Page 4344]]

     and make other modifications to the program that are 
     appropriate due to changes in demographics, needs of the 
     populations served, or other similar issues affecting the 
     area health education center program. For the purposes of 
     this section, the term `Program' refers to the area health 
     education center program.
       ``(b) Eligible Entities; Application.--
       ``(1) Eligible entities.--
       ``(A) Infrastructure development.--For purposes of 
     subsection (a)(1), the term `eligible entity' means a school 
     of medicine or osteopathic medicine, an incorporated 
     consortium of such schools, or the parent institutions of 
     such a school. With respect to a State in which no area 
     health education center program is in operation, the 
     Secretary may award a grant or contract under subsection 
     (a)(1) to a school of nursing.
       ``(B) Point of service maintenance and enhancement.--For 
     purposes of subsection (a)(2), the term `eligible entity' 
     means an entity that has received funds under this section, 
     is operating an area health education center program, 
     including an area health education center or centers, and has 
     a center or centers that are no longer eligible to receive 
     financial assistance under subsection (a)(1).
       ``(2) Application.--An eligible entity desiring to receive 
     an award under this section shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(c) Use of Funds.--
       ``(1) Required activities.--An eligible entity shall use 
     amounts awarded under a grant under subsection (a)(1) or 
     (a)(2) to carry out the following activities:
       ``(A) Develop and implement strategies, in coordination 
     with the applicable one-stop delivery system under section 
     134(c) of the Workforce Investment Act of 1998, to recruit 
     individuals from underrepresented minority populations or 
     from disadvantaged or rural backgrounds into health 
     professions, and support such individuals in attaining such 
     careers.
       ``(B) Develop and implement strategies to foster and 
     provide community-based training and education to individuals 
     seeking careers in health professions within underserved 
     areas for the purpose of developing and maintaining a diverse 
     health care workforce that is prepared to deliver high-
     quality care, with an emphasis on primary care, in 
     underserved areas or for health disparity populations, in 
     collaboration with other Federal and State health care 
     workforce development programs, the State workforce agency, 
     and local workforce investment boards, and in health care 
     safety net sites.
       ``(C) Prepare individuals to more effectively provide 
     health services to underserved areas and health disparity 
     populations through field placements or preceptorships in 
     conjunction with community-based organizations, accredited 
     primary care residency training programs, Federally qualified 
     health centers, rural health clinics, public health 
     departments, or other appropriate facilities.
       ``(D) Conduct and participate in interdisciplinary training 
     that involves physicians, physician assistants, nurse 
     practitioners, nurse midwives, dentists, psychologists, 
     pharmacists, optometrists, community health workers, public 
     and allied health professionals, or other health 
     professionals, as practicable.
       ``(E) Deliver or facilitate continuing education and 
     information dissemination programs for health care 
     professionals, with an emphasis on individuals providing care 
     in underserved areas and for health disparity populations.
       ``(F) Propose and implement effective program and outcomes 
     measurement and evaluation strategies.
       ``(G) Establish a youth public health program to expose and 
     recruit high school students into health careers, with a 
     focus on careers in public health.
       ``(2) Innovative opportunities.--An eligible entity may use 
     amounts awarded under a grant under subsection (a)(1) or 
     subsection (a)(2) to carry out any of the following 
     activities:
       ``(A) Develop and implement innovative curricula in 
     collaboration with community-based accredited primary care 
     residency training programs, Federally qualified health 
     centers, rural health clinics, behavioral and mental health 
     facilities, public health departments, or other appropriate 
     facilities, with the goal of increasing the number of primary 
     care physicians and other primary care providers prepared to 
     serve in underserved areas and health disparity populations.
       ``(B) Coordinate community-based participatory research 
     with academic health centers, and facilitate rapid flow and 
     dissemination of evidence-based health care information, 
     research results, and best practices to improve quality, 
     efficiency, and effectiveness of health care and health care 
     systems within community settings.
       ``(C) Develop and implement other strategies to address 
     identified workforce needs and increase and enhance the 
     health care workforce in the area served by the area health 
     education center program.
       ``(d) Requirements.--
       ``(1) Area health education center program.--In carrying 
     out this section, the Secretary shall ensure the following:
       ``(A) An entity that receives an award under this section 
     shall conduct at least 10 percent of clinical education 
     required for medical students in community settings that are 
     removed from the primary teaching facility of the contracting 
     institution for grantees that operate a school of medicine or 
     osteopathic medicine. In States in which an entity that 
     receives an award under this section is a nursing school or 
     its parent institution, the Secretary shall alternatively 
     ensure that--
       ``(i) the nursing school conducts at least 10 percent of 
     clinical education required for nursing students in community 
     settings that are remote from the primary teaching facility 
     of the school; and
       ``(ii) the entity receiving the award maintains a written 
     agreement with a school of medicine or osteopathic medicine 
     to place students from that school in training sites in the 
     area health education center program area.
       ``(B) An entity receiving funds under subsection (a)(2) 
     does not distribute such funding to a center that is eligible 
     to receive funding under subsection (a)(1).
       ``(2) Area health education center.--The Secretary shall 
     ensure that each area health education center program 
     includes at least 1 area health education center, and that 
     each such center--
       ``(A) is a public or private organization whose structure, 
     governance, and operation is independent from the awardee and 
     the parent institution of the awardee;
       ``(B) is not a school of medicine or osteopathic medicine, 
     the parent institution of such a school, or a branch campus 
     or other subunit of a school of medicine or osteopathic 
     medicine or its parent institution, or a consortium of such 
     entities;
       ``(C) designates an underserved area or population to be 
     served by the center which is in a location removed from the 
     main location of the teaching facilities of the schools 
     participating in the program with such center and does not 
     duplicate, in whole or in part, the geographic area or 
     population served by any other center;
       ``(D) fosters networking and collaboration among 
     communities and between academic health centers and 
     community-based centers;
       ``(E) serves communities with a demonstrated need of health 
     professionals in partnership with academic medical centers;
       ``(F) addresses the health care workforce needs of the 
     communities served in coordination with the public workforce 
     investment system; and
       ``(G) has a community-based governing or advisory board 
     that reflects the diversity of the communities involved.
       ``(e) Matching Funds.--With respect to the costs of 
     operating a program through a grant under this section, to be 
     eligible for financial assistance under this section, an 
     entity shall make available (directly or through 
     contributions from State, county or municipal governments, or 
     the private sector) recurring non-Federal contributions in 
     cash or in kind, toward such costs in an amount that is equal 
     to not less than 50 percent of such costs. At least 25 
     percent of the total required non-Federal contributions shall 
     be in cash. An entity may apply to the Secretary for a waiver 
     of not more than 75 percent of the matching fund amount 
     required by the entity for each of the first 3 years the 
     entity is funded through a grant under subsection (a)(1).
       ``(f) Limitation.--Not less than 75 percent of the total 
     amount provided to an area health education center program 
     under subsection (a)(1) or (a)(2) shall be allocated to the 
     area health education centers participating in the program 
     under this section. To provide needed flexibility to newly 
     funded area health education center programs, the Secretary 
     may waive the requirement in the sentence for the first 2 
     years of a new area health education center program funded 
     under subsection (a)(1).
       ``(g) Award.--An award to an entity under this section 
     shall be not less than $250,000 annually per area health 
     education center included in the program involved. If amounts 
     appropriated to carry out this section are not sufficient to 
     comply with the preceding sentence, the Secretary may reduce 
     the per center amount provided for in such sentence as 
     necessary, provided the distribution established in 
     subsection (j)(2) is maintained.
       ``(h) Project Terms.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     period during which payments may be made under an award under 
     subsection (a)(1) may not exceed--
       ``(A) in the case of a program, 12 years; or
       ``(B) in the case of a center within a program, 6 years.
       ``(2) Exception.--The periods described in paragraph (1) 
     shall not apply to programs receiving point of service 
     maintenance and enhancement awards under subsection (a)(2) to 
     maintain existing centers and activities.
       ``(i) Inapplicability of Provision.--Notwithstanding any 
     other provision of this title, section 791(a) shall not apply 
     to an area health education center funded under this section.
       ``(j) Authorization of Appropriations.--
       ``(1) In general.--There is authorized to be appropriated 
     to carry out this section $125,000,000 for each of the fiscal 
     years 2010 through 2014.
       ``(2) Requirements.--Of the amounts appropriated for a 
     fiscal year under paragraph (1)--
       ``(A) not more than 35 percent shall be used for awards 
     under subsection (a)(1);
       ``(B) not less than 60 percent shall be used for awards 
     under subsection (a)(2);
       ``(C) not more than 1 percent shall be used for grants and 
     contracts to implement outcomes evaluation for the area 
     health education centers; and
       ``(D) not more than 4 percent shall be used for grants and 
     contracts to provide technical assistance to entities 
     receiving awards under this section.
       ``(3) Carryover funds.--An entity that receives an award 
     under this section may carry

[[Page 4345]]

     over funds from 1 fiscal year to another without obtaining 
     approval from the Secretary. In no case may any funds be 
     carried over pursuant to the preceding sentence for more than 
     3 years.
       ``(k) Sense of Congress.--It is the sense of the Congress 
     that every State have an area health education center program 
     in effect under this section.''.
       (b) Continuing Educational Support for Health Professionals 
     Serving in Underserved Communities.--Part D of title VII of 
     the Public Health Service Act (42 U.S.C. 294 et seq.) is 
     amended by striking section 752 and inserting the following:

     ``SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR HEALTH 
                   PROFESSIONALS SERVING IN UNDERSERVED 
                   COMMUNITIES.

       ``(a) In General.--The Secretary shall make grants to, and 
     enter into contracts with, eligible entities to improve 
     health care, increase retention, increase representation of 
     minority faculty members, enhance the practice environment, 
     and provide information dissemination and educational support 
     to reduce professional isolation through the timely 
     dissemination of research findings using relevant resources.
       ``(b) Eligible Entities.--For purposes of this section, the 
     term `eligible entity' means an entity described in section 
     799(b).
       ``(c) Application.--An eligible entity desiring to receive 
     an award under this section shall submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(d) Use of Funds.--An eligible entity shall use amounts 
     awarded under a grant or contract under this section to 
     provide innovative supportive activities to enhance education 
     through distance learning, continuing educational activities, 
     collaborative conferences, and electronic and telelearning 
     activities, with priority for primary care.
       ``(e) Authorization.--There is authorized to be 
     appropriated to carry out this section $5,000,000 for each of 
     the fiscal years 2010 through 2014, and such sums as may be 
     necessary for each subsequent fiscal year.''.

     SEC. 5404. WORKFORCE DIVERSITY GRANTS.

       Section 821 of the Public Health Service Act (42 U.S.C. 
     296m) is amended--
       (1) in subsection (a)--
       (A) by striking ``The Secretary may'' and inserting the 
     following:
       ``(1) Authority.--The Secretary may'';
       (B) by striking ``pre-entry preparation, and retention 
     activities'' and inserting the following: ``stipends for 
     diploma or associate degree nurses to enter a bridge or 
     degree completion program, student scholarships or stipends 
     for accelerated nursing degree programs, pre-entry 
     preparation, advanced education preparation, and retention 
     activities''; and
       (2) in subsection (b)--
       (A) by striking ``First'' and all that follows through 
     ``including the'' and inserting ``National Advisory Council 
     on Nurse Education and Practice and consult with nursing 
     associations including the National Coalition of Ethnic 
     Minority Nurse Associations,''; and
       (B) by inserting before the period the following: ``, and 
     other organizations determined appropriate by the 
     Secretary''.

     SEC. 5405. PRIMARY CARE EXTENSION PROGRAM.

       Part P of title III of the Public Health Service Act (42 
     U.S.C. 280g et seq.), as amended by section 5313, is further 
     amended by adding at the end the following:

     ``SEC. 399W. PRIMARY CARE EXTENSION PROGRAM.

       ``(a) Establishment, Purpose and Definition.--
       ``(1) In general.--The Secretary, acting through the 
     Director of the Agency for Healthcare Research and Quality, 
     shall establish a Primary Care Extension Program.
       ``(2) Purpose.--The Primary Care Extension Program shall 
     provide support and assistance to primary care providers to 
     educate providers about preventive medicine, health 
     promotion, chronic disease management, mental and behavioral 
     health services (including substance abuse prevention and 
     treatment services), and evidence-based and evidence-informed 
     therapies and techniques, in order to enable providers to 
     incorporate such matters into their practice and to improve 
     community health by working with community-based health 
     connectors (referred to in this section as `Health Extension 
     Agents').
       ``(3) Definitions.--In this section:
       ``(A) Health extension agent.--The term `Health Extension 
     Agent' means any local, community-based health worker who 
     facilitates and provides assistance to primary care practices 
     by implementing quality improvement or system redesign, 
     incorporating the principles of the patient-centered medical 
     home to provide high-quality, effective, efficient, and safe 
     primary care and to provide guidance to patients in 
     culturally and linguistically appropriate ways, and linking 
     practices to diverse health system resources.
       ``(B) Primary care provider.--The term `primary care 
     provider' means a clinician who provides integrated, 
     accessible health care services and who is accountable for 
     addressing a large majority of personal health care needs, 
     including providing preventive and health promotion services 
     for men, women, and children of all ages, developing a 
     sustained partnership with patients, and practicing in the 
     context of family and community, as recognized by a State 
     licensing or regulatory authority, unless otherwise specified 
     in this section.
       ``(b) Grants To Establish State Hubs and Local Primary Care 
     Extension Agencies.--
       ``(1) Grants.--The Secretary shall award competitive grants 
     to States for the establishment of State- or multistate-level 
     primary care Primary Care Extension Program State Hubs 
     (referred to in this section as `Hubs').
       ``(2) Composition of hubs.--A Hub established by a State 
     pursuant to paragraph (1)--
       ``(A) shall consist of, at a minimum, the State health 
     department, the entity responsible for administering the 
     State Medicaid program (if other than the State health 
     department), the State-level entity administering the 
     Medicare program, and the departments of 1 or more health 
     professions schools in the State that train providers in 
     primary care; and
       ``(B) may include entities such as hospital associations, 
     primary care practice-based research networks, health 
     professional societies, State primary care associations, 
     State licensing boards, organizations with a contract with 
     the Secretary under section 1153 of the Social Security Act, 
     consumer groups, and other appropriate entities.
       ``(c) State and Local Activities.--
       ``(1) Hub activities.--Hubs established under a grant under 
     subsection (b) shall--
       ``(A) submit to the Secretary a plan to coordinate 
     functions with quality improvement organizations and area 
     health education centers if such entities are members of the 
     Hub not described in subsection (b)(2)(A);
       ``(B) contract with a county- or local-level entity that 
     shall serve as the Primary Care Extension Agency to 
     administer the services described in paragraph (2);
       ``(C) organize and administer grant funds to county- or 
     local-level Primary Care Extension Agencies that serve a 
     catchment area, as determined by the State; and
       ``(D) organize State-wide or multistate networks of local-
     level Primary Care Extension Agencies to share and 
     disseminate information and practices.
       ``(2) Local primary care extension agency activities.--
       ``(A) Required activities.--Primary Care Extension Agencies 
     established by a Hub under paragraph (1) shall--
       ``(i) assist primary care providers to implement a patient-
     centered medical home to improve the accessibility, quality, 
     and efficiency of primary care services, including health 
     homes;
       ``(ii) develop and support primary care learning 
     communities to enhance the dissemination of research findings 
     for evidence-based practice, assess implementation of 
     practice improvement, share best practices, and involve 
     community clinicians in the generation of new knowledge and 
     identification of important questions for research;
       ``(iii) participate in a national network of Primary Care 
     Extension Hubs and propose how the Primary Care Extension 
     Agency will share and disseminate lessons learned and best 
     practices; and
       ``(iv) develop a plan for financial sustainability 
     involving State, local, and private contributions, to provide 
     for the reduction in Federal funds that is expected after an 
     initial 6-year period of program establishment, 
     infrastructure development, and planning.
       ``(B) Discretionary activities.--Primary Care Extension 
     Agencies established by a Hub under paragraph (1) may--
       ``(i) provide technical assistance, training, and 
     organizational support for community health teams established 
     under section 3602 of the Patient Protection and Affordable 
     Care Act;
       ``(ii) collect data and provision of primary care provider 
     feedback from standardized measurements of processes and 
     outcomes to aid in continuous performance improvement;
       ``(iii) collaborate with local health departments, 
     community health centers, tribes and tribal entities, and 
     other community agencies to identify community health 
     priorities and local health workforce needs, and participate 
     in community-based efforts to address the social and primary 
     determinants of health, strengthen the local primary care 
     workforce, and eliminate health disparities;
       ``(iv) develop measures to monitor the impact of the 
     proposed program on the health of practice enrollees and of 
     the wider community served; and
       ``(v) participate in other activities, as determined 
     appropriate by the Secretary.
       ``(d) Federal Program Administration.--
       ``(1) Grants; types.--Grants awarded under subsection (b) 
     shall be--
       ``(A) program grants, that are awarded to State or 
     multistate entities that submit fully-developed plans for the 
     implementation of a Hub, for a period of 6 years; or
       ``(B) planning grants, that are awarded to State or 
     multistate entities with the goal of developing a plan for a 
     Hub, for a period of 2 years.
       ``(2) Applications.--To be eligible for a grant under 
     subsection (b), a State or multistate entity shall submit to 
     the Secretary an application, at such time, in such manner, 
     and containing such information as the Secretary may require.
       ``(3) Evaluation.--A State that receives a grant under 
     subsection (b) shall be evaluated at the end of the grant 
     period by an evaluation panel appointed by the Secretary.
       ``(4) Continuing support.--After the sixth year in which 
     assistance is provided to a State under a grant awarded under 
     subsection (b), the State may receive additional support 
     under this section if the State program has received 
     satisfactory evaluations with respect to program performance 
     and the merits of the State sustainability plan, as 
     determined by the Secretary.
       ``(5) Limitation.--A State shall not use in excess of 10 
     percent of the amount received under

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     a grant to carry out administrative activities under this 
     section. Funds awarded pursuant to this section shall not be 
     used for funding direct patient care.
       ``(e) Requirements on the Secretary.--In carrying out this 
     section, the Secretary shall consult with the heads of other 
     Federal agencies with demonstrated experience and expertise 
     in health care and preventive medicine, such as the Centers 
     for Disease Control and Prevention, the Substance Abuse and 
     Mental Health Administration, the Health Resources and 
     Services Administration, the National Institutes of Health, 
     the Office of the National Coordinator for Health Information 
     Technology, the Indian Health Service, the Agricultural 
     Cooperative Extension Service of the Department of 
     Agriculture, and other entities, as the Secretary determines 
     appropriate.
       ``(f) Authorization of Appropriations.--To awards grants as 
     provided in subsection (d), there are authorized to be 
     appropriated $120,000,000 for each of fiscal years 2011 and 
     2012, and such sums as may be necessary to carry out this 
     section for each of fiscal years 2013 through 2014.''.

Subtitle F--Strengthening Primary Care and Other Workforce Improvements

     SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND 
                   GENERAL SURGERY SERVICES.

       (a) Incentive Payment Program for Primary Care Services.--
       (1) In general.--Section 1833 of the Social Security Act 
     (42 U.S.C. 1395l) is amended by adding at the end the 
     following new subsection:
       ``(x) Incentive Payments for Primary Care Services.--
       ``(1) In general.--In the case of primary care services 
     furnished on or after January 1, 2011, and before January 1, 
     2016, by a primary care practitioner, in addition to the 
     amount of payment that would otherwise be made for such 
     services under this part, there also shall be paid (on a 
     monthly or quarterly basis) an amount equal to 10 percent of 
     the payment amount for the service under this part.
       ``(2) Definitions.--In this subsection:
       ``(A) Primary care practitioner.--The term `primary care 
     practitioner' means an individual--
       ``(i) who--

       ``(I) is a physician (as described in section 1861(r)(1)) 
     who has a primary specialty designation of family medicine, 
     internal medicine, geriatric medicine, or pediatric medicine; 
     or
       ``(II) is a nurse practitioner, clinical nurse specialist, 
     or physician assistant (as those terms are defined in section 
     1861(aa)(5)); and

       ``(ii) for whom primary care services accounted for at 
     least 60 percent of the allowed charges under this part for 
     such physician or practitioner in a prior period as 
     determined appropriate by the Secretary.
       ``(B) Primary care services.--The term `primary care 
     services' means services identified, as of January 1, 2009, 
     by the following HCPCS codes (and as subsequently modified by 
     the Secretary):
       ``(i) 99201 through 99215.
       ``(ii) 99304 through 99340.
       ``(iii) 99341 through 99350.
       ``(3) Coordination with other payments.--The amount of the 
     additional payment for a service under this subsection and 
     subsection (m) shall be determined without regard to any 
     additional payment for the service under subsection (m) and 
     this subsection, respectively.
       ``(4) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, 1878, 
     or otherwise, respecting the identification of primary care 
     practitioners under this subsection.''.
       (2) Conforming amendment.--Section 1834(g)(2)(B) of the 
     Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by 
     adding at the end the following sentence: ``Section 1833(x) 
     shall not be taken into account in determining the amounts 
     that would otherwise be paid pursuant to the preceding 
     sentence.''.
       (b) Incentive Payment Program for Major Surgical Procedures 
     Furnished in Health Professional Shortage Areas.--
       (1) In general.--Section 1833 of the Social Security Act 
     (42 U.S.C. 1395l), as amended by subsection (a)(1), is 
     amended by adding at the end the following new subsection:
       ``(y) Incentive Payments for Major Surgical Procedures 
     Furnished in Health Professional Shortage Areas.--
       ``(1) In general.--In the case of major surgical procedures 
     furnished on or after January 1, 2011, and before January 1, 
     2016, by a general surgeon in an area that is designated 
     (under section 332(a)(1)(A) of the Public Health Service Act) 
     as a health professional shortage area as identified by the 
     Secretary prior to the beginning of the year involved, in 
     addition to the amount of payment that would otherwise be 
     made for such services under this part, there also shall be 
     paid (on a monthly or quarterly basis) an amount equal to 10 
     percent of the payment amount for the service under this 
     part.
       ``(2) Definitions.--In this subsection:
       ``(A) General surgeon.--In this subsection, the term 
     `general surgeon' means a physician (as described in section 
     1861(r)(1)) who has designated CMS specialty code 02-General 
     Surgery as their primary specialty code in the physician's 
     enrollment under section 1866(j).
       ``(B) Major surgical procedures.--The term `major surgical 
     procedures' means physicians' services which are surgical 
     procedures for which a 10-day or 90-day global period is used 
     for payment under the fee schedule under section 1848(b).
       ``(3) Coordination with other payments.--The amount of the 
     additional payment for a service under this subsection and 
     subsection (m) shall be determined without regard to any 
     additional payment for the service under subsection (m) and 
     this subsection, respectively.
       ``(4) Application.--The provisions of paragraph (2) and (4) 
     of subsection (m) shall apply to the determination of 
     additional payments under this subsection in the same manner 
     as such provisions apply to the determination of additional 
     payments under subsection (m).''.
       (2) Conforming amendment.--Section 1834(g)(2)(B) of the 
     Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended by 
     subsection (a)(2), is amended by striking ``Section 1833(x)'' 
     and inserting ``Subsections (x) and (y) of section 1833'' in 
     the last sentence.
       (c) Budget-neutrality Adjustment.--Section 1848(c)(2)(B) of 
     the Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is 
     amended by adding at the end the following new clause:
       ``(vii) Adjustment for certain physician incentive 
     payments.--Fifty percent of the additional expenditures under 
     this part attributable to subsections (x) and (y) of section 
     1833 for a year (as estimated by the Secretary) shall be 
     taken into account in applying clause (ii)(II) for 2011 and 
     subsequent years. In lieu of applying the budget-neutrality 
     adjustments required under clause (ii)(II) to relative value 
     units to account for such costs for the year, the Secretary 
     shall apply such budget-neutrality adjustments to the 
     conversion factor otherwise determined for the year. For 2011 
     and subsequent years, the Secretary shall increase the 
     incentive payment otherwise applicable under section 1833(m) 
     by a percent estimated to be equal to the additional 
     expenditures estimated under the first sentence of this 
     clause for such year that is applicable to physicians who 
     primarily furnish services in areas designated (under section 
     332(a)(1)(A) of the Public Health Service Act) as health 
     professional shortage areas.''.

     SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER 
                   IMPROVEMENTS.

       (a)  Expansion of Medicare-Covered Preventive Services at 
     Federally Qualified Health Centers.--
       (1) In general.--Section 1861(aa)(3)(A) of the Social 
     Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read 
     as follows:
       ``(A) services of the type described subparagraphs (A) 
     through (C) of paragraph (1) and preventive services (as 
     defined in section 1861(ddd)(3)); and''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to services furnished on or after January 1, 
     2011.
       (b) Prospective Payment System for Federally Qualified 
     Health Centers.--Section 1834 of the Social Security Act (42 
     U.S.C. 1395m) is amended by adding at the end the following 
     new subsection:
       ``(n) Development and Implementation of Prospective Payment 
     System.--
       ``(1) Development.--
       ``(A) In general.--The Secretary shall develop a 
     prospective payment system for payment for Federally 
     qualified health services furnished by Federally qualified 
     health centers under this title. Such system shall include a 
     process for appropriately describing the services furnished 
     by Federally qualified health centers.
       ``(B) Collection of data and evaluation.--The Secretary 
     shall require Federally qualified health centers to submit to 
     the Secretary such information as the Secretary may require 
     in order to develop and implement the prospective payment 
     system under this paragraph and paragraph (2), respectively, 
     including the reporting of services using HCPCS codes.
       ``(2) Implementation.--
       ``(A) In general.--Notwithstanding section 1833(a)(3)(B), 
     the Secretary shall provide, for cost reporting periods 
     beginning on or after October 1, 2014, for payments for 
     Federally qualified health services furnished by Federally 
     qualified health centers under this title in accordance with 
     the prospective payment system developed by the Secretary 
     under paragraph (1).
       ``(B) Payments.--
       ``(i) Initial payments.--The Secretary shall implement such 
     prospective payment system so that the estimated amount of 
     expenditures under this title for Federally qualified health 
     services in the first year that the prospective payment 
     system is implemented is equal to 103 percent of the 
     estimated amount of expenditures under this title that would 
     have occurred for such services in such year if the system 
     had not been implemented.
       ``(ii) Payments in subsequent years.--In the year after the 
     first year of implementation of such system, and in each 
     subsequent year, the payment rate for Federally qualified 
     health services furnished in the year shall be equal to the 
     payment rate established for such services furnished in the 
     preceding year under this subparagraph increased by the 
     percentage increase in the MEI (as defined in 1842(i)(3)) for 
     the year involved.''.

     SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS.

       (a) In General.--Section 1886(h) of the Social Security Act 
     (42 U.S.C. 1395ww(h)) is amended--
       (1) in paragraph (4)(F)(i), by striking ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)'';
       (2) in paragraph (4)(H)(i), by striking ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)'';
       (3) in paragraph (7)(E), by inserting ``or paragraph (8)'' 
     before the period at the end; and
       (4) by adding at the end the following new paragraph:
       ``(8) Distribution of additional residency positions.--

[[Page 4347]]

       ``(A) Reductions in limit based on unused positions.--
       ``(i) In general.--Except as provided in clause (ii), if a 
     hospital's reference resident level (as defined in 
     subparagraph (H)(i)) is less than the otherwise applicable 
     resident limit (as defined in subparagraph (H)(iii)), 
     effective for portions of cost reporting periods occurring on 
     or after July 1, 2011, the otherwise applicable resident 
     limit shall be reduced by 65 percent of the difference 
     between such otherwise applicable resident limit and such 
     reference resident level.
       ``(ii) Exceptions.--This subparagraph shall not apply to--

       ``(I) a hospital located in a rural area (as defined in 
     subsection (d)(2)(D)(ii)) with fewer than 250 acute care 
     inpatient beds;
       ``(II) a hospital that was part of a qualifying entity 
     which had a voluntary residency reduction plan approved under 
     paragraph (6)(B) or under the authority of section 402 of 
     Public Law 90-248, if the hospital demonstrates to the 
     Secretary that it has a specified plan in place for filling 
     the unused positions by not later than 2 years after the date 
     of enactment of this paragraph; or
       ``(III) a hospital described in paragraph (4)(H)(v).

       ``(B) Distribution.--
       ``(i) In general.--The Secretary shall increase the 
     otherwise applicable resident limit for each qualifying 
     hospital that submits an application under this subparagraph 
     by such number as the Secretary may approve for portions of 
     cost reporting periods occurring on or after July 1, 2011. 
     The aggregate number of increases in the otherwise applicable 
     resident limit under this subparagraph shall be equal to the 
     aggregate reduction in such limits attributable to 
     subparagraph (A) (as estimated by the Secretary).
       ``(ii) Requirements.--Subject to clause (iii), a hospital 
     that receives an increase in the otherwise applicable 
     resident limit under this subparagraph shall ensure, during 
     the 5-year period beginning on the date of such increase, 
     that--

       ``(I) the number of full-time equivalent primary care 
     residents, as defined in paragraph (5)(H) (as determined by 
     the Secretary), excluding any additional positions under 
     subclause (II), is not less than the average number of full-
     time equivalent primary care residents (as so determined) 
     during the 3 most recent cost reporting periods ending prior 
     to the date of enactment of this paragraph; and
       ``(II) not less than 75 percent of the positions 
     attributable to such increase are in a primary care or 
     general surgery residency (as determined by the Secretary).

     The Secretary may determine whether a hospital has met the 
     requirements under this clause during such 5-year period in 
     such manner and at such time as the Secretary determines 
     appropriate, including at the end of such 5-year period.
       ``(iii) Redistribution of positions if hospital no longer 
     meets certain requirements.--In the case where the Secretary 
     determines that a hospital described in clause (ii) does not 
     meet either of the requirements under subclause (I) or (II) 
     of such clause, the Secretary shall--

       ``(I) reduce the otherwise applicable resident limit of the 
     hospital by the amount by which such limit was increased 
     under this paragraph; and
       ``(II) provide for the distribution of positions 
     attributable to such reduction in accordance with the 
     requirements of this paragraph.

       ``(C) Considerations in redistribution.--In determining for 
     which hospitals the increase in the otherwise applicable 
     resident limit is provided under subparagraph (B), the 
     Secretary shall take into account--
       ``(i) the demonstration likelihood of the hospital filling 
     the positions made available under this paragraph within the 
     first 3 cost reporting periods beginning on or after July 1, 
     2011, as determined by the Secretary; and
       ``(ii) whether the hospital has an accredited rural 
     training track (as described in paragraph (4)(H)(iv)).
       ``(D) Priority for certain areas.--In determining for which 
     hospitals the increase in the otherwise applicable resident 
     limit is provided under subparagraph (B), subject to 
     subparagraph (E), the Secretary shall distribute the increase 
     to hospitals based on the following factors:
       ``(i) Whether the hospital is located in a State with a 
     resident-to-population ratio in the lowest quartile (as 
     determined by the Secretary).
       ``(ii) Whether the hospital is located in a State, a 
     territory of the United States, or the District of Columbia 
     that is among the top 10 States, territories, or Districts in 
     terms of the ratio of--

       ``(I) the total population of the State, territory, or 
     District living in an area designated (under such section 
     332(a)(1)(A)) as a health professional shortage area (as of 
     the date of enactment of this paragraph); to
       ``(II) the total population of the State, territory, or 
     District (as determined by the Secretary based on the most 
     recent available population data published by the Bureau of 
     the Census).

       ``(iii) Whether the hospital is located in a rural area (as 
     defined in subsection (d)(2)(D)(ii)).
       ``(E) Reservation of positions for certain hospitals.--
       ``(i) In general.--Subject to clause (ii), the Secretary 
     shall reserve the positions available for distribution under 
     this paragraph as follows:

       ``(I) 70 percent of such positions for distribution to 
     hospitals described in clause (i) of subparagraph (D).
       ``(II) 30 percent of such positions for distribution to 
     hospitals described in clause (ii) and (iii) of such 
     subparagraph.

       ``(ii) Exception if positions not redistributed by july 1, 
     2011.--In the case where the Secretary does not distribute 
     positions to hospitals in accordance with clause (i) by July 
     1, 2011, the Secretary shall distribute such positions to 
     other hospitals in accordance with the considerations 
     described in subparagraph (C) and the priority described in 
     subparagraph (D).
       ``(F) Limitation.--A hospital may not receive more than 75 
     full-time equivalent additional residency positions under 
     this paragraph.
       ``(G) Application of per resident amounts for primary care 
     and nonprimary care.--With respect to additional residency 
     positions in a hospital attributable to the increase provided 
     under this paragraph, the approved FTE per resident amounts 
     are deemed to be equal to the hospital per resident amounts 
     for primary care and nonprimary care computed under paragraph 
     (2)(D) for that hospital.
       ``(H) Definitions.--In this paragraph:
       ``(i) Reference resident level.--The term `reference 
     resident level' means, with respect to a hospital, the 
     highest resident level for any of the 3 most recent cost 
     reporting periods (ending before the date of the enactment of 
     this paragraph) of the hospital for which a cost report has 
     been settled (or, if not, submitted (subject to audit)), as 
     determined by the Secretary.
       ``(ii) Resident level.--The term `resident level' has the 
     meaning given such term in paragraph (7)(C)(i).
       ``(iii) Otherwise applicable resident limit.--The term 
     `otherwise applicable resident limit' means, with respect to 
     a hospital, the limit otherwise applicable under 
     subparagraphs (F)(i) and (H) of paragraph (4) on the resident 
     level for the hospital determined without regard to this 
     paragraph but taking into account paragraph (7)(A).''.
       (b) IME.--
       (1) In general.--Section 1886(d)(5)(B)(v) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second 
     sentence, is amended--
       (A) by striking ``subsection (h)(7)'' and inserting 
     ``subsections (h)(7) and (h)(8)''; and
       (B) by striking ``it applies'' and inserting ``they 
     apply''.
       (2) Conforming amendment.--Section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
     adding at the end the following clause:
       ``(x) For discharges occurring on or after July 1, 2011, 
     insofar as an additional payment amount under this 
     subparagraph is attributable to resident positions 
     distributed to a hospital under subsection (h)(8)(B), the 
     indirect teaching adjustment factor shall be computed in the 
     same manner as provided under clause (ii) with respect to 
     such resident positions.''.
       (c) Conforming Amendment.--Section 422(b)(2) of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (Public Law 108-173) is amended by striking 
     ``section 1886(h)(7)'' and all that follows and inserting 
     ``paragraphs (7) and (8) of subsection (h) of section 1886 of 
     the Social Security Act''.

     SEC. 5504. COUNTING RESIDENT TIME IN NONPROVIDER SETTINGS.

       (a) GME.--Section 1886(h)(4)(E) of the Social Security Act 
     (42 U.S.C. 1395ww(h)(4)(E)) is amended--
       (1) by striking ``shall be counted and that all the time'' 
     and inserting ``shall be counted and that--
       ``(i) effective for cost reporting periods beginning before 
     July 1, 2010, all the time;'';
       (2) in clause (i), as inserted by paragraph (1), by 
     striking the period at the end and inserting ``; and'';
       (3) by inserting after clause (i), as so inserted, the 
     following new clause:
       ``(ii) effective for cost reporting periods beginning on or 
     after July 1, 2010, all the time so spent by a resident shall 
     be counted towards the determination of full-time 
     equivalency, without regard to the setting in which the 
     activities are performed, if a hospital incurs the costs of 
     the stipends and fringe benefits of the resident during the 
     time the resident spends in that setting. If more than one 
     hospital incurs these costs, either directly or through a 
     third party, such hospitals shall count a proportional share 
     of the time, as determined by written agreement between the 
     hospitals, that a resident spends training in that 
     setting.''; and
       (4) by adding at the end the following flush sentence:

     ``Any hospital claiming under this subparagraph for time 
     spent in a nonprovider setting shall maintain and make 
     available to the Secretary records regarding the amount of 
     such time and such amount in comparison with amounts of such 
     time in such base year as the Secretary shall specify.''.
       (b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)) is amended--
       (1) by striking ``(iv) Effective for discharges occurring 
     on or after October 1, 1997'' and inserting ``(iv)(I) 
     Effective for discharges occurring on or after October 1, 
     1997, and before July 1, 2010''; and
       (2) by inserting after clause (I), as inserted by paragraph 
     (1), the following new subparagraph:
       ``(II) Effective for discharges occurring on or after July 
     1, 2010, all the time spent by an intern or resident in 
     patient care activities in a nonprovider setting shall be 
     counted towards the determination of full-time equivalency if 
     a hospital incurs the costs of the stipends and fringe

[[Page 4348]]

     benefits of the intern or resident during the time the intern 
     or resident spends in that setting. If more than one hospital 
     incurs these costs, either directly or through a third party, 
     such hospitals shall count a proportional share of the time, 
     as determined by written agreement between the hospitals, 
     that a resident spends training in that setting.''.
       (c) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct 
     graduate medical education costs under section 1886(h) of 
     such Act (42 U.S.C. 1395ww(h)).

     SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND 
                   SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

       (a) GME.--Section 1886(h) of the Social Security Act (42 
     U.S.C. 1395ww(h)), as amended by section 5504, is amended--
       (1) in paragraph (4)--
       (A) in subparagraph (E), by striking ``Such rules'' and 
     inserting ``Subject to subparagraphs (J) and (K), such 
     rules''; and
       (B) by adding at the end the following new subparagraphs:
       ``(J) Treatment of certain nonprovider and didactic 
     activities.--Such rules shall provide that all time spent by 
     an intern or resident in an approved medical residency 
     training program in a nonprovider setting that is primarily 
     engaged in furnishing patient care (as defined in paragraph 
     (5)(K)) in non-patient care activities, such as didactic 
     conferences and seminars, but not including research not 
     associated with the treatment or diagnosis of a particular 
     patient, as such time and activities are defined by the 
     Secretary, shall be counted toward the determination of full-
     time equivalency.
       ``(K) Treatment of certain other activities.--In 
     determining the hospital's number of full-time equivalent 
     residents for purposes of this subsection, all the time that 
     is spent by an intern or resident in an approved medical 
     residency training program on vacation, sick leave, or other 
     approved leave, as such time is defined by the Secretary, and 
     that does not prolong the total time the resident is 
     participating in the approved program beyond the normal 
     duration of the program shall be counted toward the 
     determination of full-time equivalency.''; and
       (2) in paragraph (5), by adding at the end the following 
     new subparagraph:
       ``(K) Nonprovider setting that is primarily engaged in 
     furnishing patient care.--The term `nonprovider setting that 
     is primarily engaged in furnishing patient care' means a 
     nonprovider setting in which the primary activity is the care 
     and treatment of patients, as defined by the Secretary.''.
       (b) IME Determinations.--Section 1886(d)(5)(B) of such Act 
     (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end 
     the following new clause:
       ``(x)(I) The provisions of subparagraph (K) of subsection 
     (h)(4) shall apply under this subparagraph in the same manner 
     as they apply under such subsection.
       ``(II) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by an intern or resident in an approved 
     medical residency training program in non-patient care 
     activities, such as didactic conferences and seminars, as 
     such time and activities are defined by the Secretary, that 
     occurs in the hospital shall be counted toward the 
     determination of full-time equivalency if the hospital--

       ``(aa) is recognized as a subsection (d) hospital;
       ``(bb) is recognized as a subsection (d) Puerto Rico 
     hospital;
       ``(cc) is reimbursed under a reimbursement system 
     authorized under section 1814(b)(3); or
       ``(dd) is a provider-based hospital outpatient department.

       ``(III) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by an intern or resident in an approved 
     medical residency training program in research activities 
     that are not associated with the treatment or diagnosis of a 
     particular patient, as such time and activities are defined 
     by the Secretary, shall not be counted toward the 
     determination of full-time equivalency.''.
       (c) Effective Dates.--
       (1) In general.--Except as otherwise provided, the 
     Secretary of Health and Human Services shall implement the 
     amendments made by this section in a manner so as to apply to 
     cost reporting periods beginning on or after January 1, 1983.
       (2) GME.--Section 1886(h)(4)(J) of the Social Security Act, 
     as added by subsection (a)(1)(B), shall apply to cost 
     reporting periods beginning on or after July 1, 2009.
       (3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social 
     Security Act, as added by subsection (b), shall apply to cost 
     reporting periods beginning on or after October 1, 2001. Such 
     section, as so added, shall not give rise to any inference as 
     to how the law in effect prior to such date should be 
     interpreted.

     SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED 
                   HOSPITALS.

       (a) GME.--Section 1886(h)(4)(H) of the Social Security Act 
     (42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at 
     the end the following new clause:
       ``(vi) Redistribution of residency slots after a hospital 
     closes.--

       ``(I) In general.--Subject to the succeeding provisions of 
     this clause, the Secretary shall, by regulation, establish a 
     process under which, in the case where a hospital (other than 
     a hospital described in clause (v)) with an approved medical 
     residency program closes on or after a date that is 2 years 
     before the date of enactment of this clause, the Secretary 
     shall increase the otherwise applicable resident limit under 
     this paragraph for other hospitals in accordance with this 
     clause.
       ``(II) Priority for hospitals in certain areas.--Subject to 
     the succeeding provisions of this clause, in determining for 
     which hospitals the increase in the otherwise applicable 
     resident limit is provided under such process, the Secretary 
     shall distribute the increase to hospitals in the following 
     priority order (with preference given within each category to 
     hospitals that are members of the same affiliated group (as 
     defined by the Secretary under clause (ii)) as the closed 
     hospital):

       ``(aa) First, to hospitals located in the same core-based 
     statistical area as, or a core-based statistical area 
     contiguous to, the hospital that closed.
       ``(bb) Second, to hospitals located in the same State as 
     the hospital that closed.
       ``(cc) Third, to hospitals located in the same region of 
     the country as the hospital that closed.
       ``(dd) Fourth, only if the Secretary is not able to 
     distribute the increase to hospitals described in item (cc), 
     to qualifying hospitals in accordance with the provisions of 
     paragraph (8).

       ``(III) Requirement hospital likely to fill position within 
     certain time period.--The Secretary may only increase the 
     otherwise applicable resident limit of a hospital under such 
     process if the Secretary determines the hospital has 
     demonstrated a likelihood of filling the positions made 
     available under this clause within 3 years.
       ``(IV) Limitation.--The aggregate number of increases in 
     the otherwise applicable resident limits for hospitals under 
     this clause shall be equal to the number of resident 
     positions in the approved medical residency programs that 
     closed on or after the date described in subclause (I).
       ``(V) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to the implementation of this 
     clause.''.

       (b) IME.--Section 1886(d)(5)(B)(v) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, 
     as amended by section 5503, is amended by striking 
     ``subsections (h)(7) and (h)(8)'' and inserting ``subsections 
     (h)(4)(H)(vi), (h)(7), and (h)(8)''.
       (c) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct 
     graduate medical education costs under section 1886(h) of 
     such Act (42 U.S.C. Section 1395ww(h)).
       (d) Effect on Temporary FTE Cap Adjustments.--The Secretary 
     of Health and Human Services shall give consideration to the 
     effect of the amendments made by this section on any 
     temporary adjustment to a hospital's FTE cap under section 
     413.79(h) of title 42, Code of Federal Regulations (as in 
     effect on the date of enactment of this Act) in order to 
     ensure that there is no duplication of FTE slots. Such 
     amendments shall not affect the application of section 
     1886(h)(4)(H)(v) of the Social Security Act (42 U.S.C. 
     1395ww(h)(4)(H)(v)).
       (e) Conforming Amendment.--Section 1886(h)(7)(E) of the 
     Social Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended 
     by section 5503(a), is amended by striking ``paragraph or 
     paragraph (8)'' and inserting ``this paragraph, paragraph 
     (8), or paragraph (4)(H)(vi)''.

     SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH 
                   PROFESSIONS WORKFORCE NEEDS; EXTENSION OF 
                   FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS.

       (a) Authority To Conduct Demonstration Projects.--Title XX 
     of the Social Security Act (42 U.S.C. 1397 et seq.) is 
     amended by adding at the end the following:

     ``SEC. 2008. DEMONSTRATION PROJECTS TO ADDRESS HEALTH 
                   PROFESSIONS WORKFORCE NEEDS.

       ``(a) Demonstration Projects To Provide Low-Income 
     Individuals With Opportunities for Education, Training, and 
     Career Advancement To Address Health Professions Workforce 
     Needs.--
       ``(1) Authority to award grants.--The Secretary, in 
     consultation with the Secretary of Labor, shall award grants 
     to eligible entities to conduct demonstration projects that 
     are designed to provide eligible individuals with the 
     opportunity to obtain education and training for occupations 
     in the health care field that pay well and are expected to 
     either experience labor shortages or be in high demand.
       ``(2) Requirements.--
       ``(A) Aid and supportive services.--
       ``(i) In general.--A demonstration project conducted by an 
     eligible entity awarded a grant under this section shall, if 
     appropriate, provide eligible individuals participating in 
     the project with financial aid, child care, case management, 
     and other supportive services.
       ``(ii) Treatment.--Any aid, services, or incentives 
     provided to an eligible beneficiary participating in a 
     demonstration project under this section shall not be 
     considered income, and shall

[[Page 4349]]

     not be taken into account for purposes of determining the 
     individual's eligibility for, or amount of, benefits under 
     any means-tested program.
       ``(B) Consultation and coordination.--An eligible entity 
     applying for a grant to carry out a demonstration project 
     under this section shall demonstrate in the application that 
     the entity has consulted with the State agency responsible 
     for administering the State TANF program, the local workforce 
     investment board in the area in which the project is to be 
     conducted (unless the applicant is such board), the State 
     workforce investment board established under section 111 of 
     the Workforce Investment Act of 1998, and the State 
     Apprenticeship Agency recognized under the Act of August 16, 
     1937 (commonly known as the `National Apprenticeship Act') 
     (or if no agency has been recognized in the State, the Office 
     of Apprenticeship of the Department of Labor) and that the 
     project will be carried out in coordination with such 
     entities.
       ``(C) Assurance of opportunities for indian populations.--
     The Secretary shall award at least 3 grants under this 
     subsection to an eligible entity that is an Indian tribe, 
     tribal organization, or Tribal College or University.
       ``(3) Reports and evaluation.--
       ``(A) Eligible entities.--An eligible entity awarded a 
     grant to conduct a demonstration project under this 
     subsection shall submit interim reports to the Secretary on 
     the activities carried out under the project and a final 
     report on such activities upon the conclusion of the 
     entities' participation in the project. Such reports shall 
     include assessments of the effectiveness of such activities 
     with respect to improving outcomes for the eligible 
     individuals participating in the project and with respect to 
     addressing health professions workforce needs in the areas in 
     which the project is conducted.
       ``(B) Evaluation.--The Secretary shall, by grant, contract, 
     or interagency agreement, evaluate the demonstration projects 
     conducted under this subsection. Such evaluation shall 
     include identification of successful activities for creating 
     opportunities for developing and sustaining, particularly 
     with respect to low-income individuals and other entry-level 
     workers, a health professions workforce that has accessible 
     entry points, that meets high standards for education, 
     training, certification, and professional development, and 
     that provides increased wages and affordable benefits, 
     including health care coverage, that are responsive to the 
     workforce's needs.
       ``(C) Report to congress.--The Secretary shall submit 
     interim reports and, based on the evaluation conducted under 
     subparagraph (B), a final report to Congress on the 
     demonstration projects conducted under this subsection.
       ``(4) Definitions.--In this subsection:
       ``(A) Eligible entity.--The term `eligible entity' means a 
     State, an Indian tribe or tribal organization, an institution 
     of higher education, a local workforce investment board 
     established under section 117 of the Workforce Investment Act 
     of 1998, a sponsor of an apprenticeship program registered 
     under the National Apprenticeship Act or a community-based 
     organization.
       ``(B) Eligible individual.--
       ``(i) In general.--The term `eligible individual' means a 
     individual receiving assistance under the State TANF program.
       ``(ii) Other low-income individuals.--Such term may include 
     other low-income individuals described by the eligible entity 
     in its application for a grant under this section.
       ``(C) Indian tribe; tribal organization.--The terms `Indian 
     tribe' and `tribal organization' have the meaning given such 
     terms in section 4 of the Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450b).
       ``(D) Institution of higher education.--The term 
     `institution of higher education' has the meaning given that 
     term in section 101 of the Higher Education Act of 1965 (20 
     U.S.C. 1001).
       ``(E) State.--The term `State' means each of the 50 States, 
     the District of Columbia, the Commonwealth of Puerto Rico, 
     the United States Virgin Islands, Guam, and American Samoa.
       ``(F) State tanf program.--The term `State TANF program' 
     means the temporary assistance for needy families program 
     funded under part A of title IV.
       ``(G) Tribal college or university.--The term `Tribal 
     College or University' has the meaning given that term in 
     section 316(b) of the Higher Education Act of 1965 (20 U.S.C. 
     1059c(b)).
       ``(b) Demonstration Project To Develop Training and 
     Certification Programs for Personal or Home Care Aides.--
       ``(1) Authority to award grants.--Not later than 18 months 
     after the date of enactment of this section, the Secretary 
     shall award grants to eligible entities that are States to 
     conduct demonstration projects for purposes of developing 
     core training competencies and certification programs for 
     personal or home care aides. The Secretary shall--
       ``(A) evaluate the efficacy of the core training 
     competencies described in paragraph (3)(A) for newly hired 
     personal or home care aides and the methods used by States to 
     implement such core training competencies in accordance with 
     the issues specified in paragraph (3)(B); and
       ``(B) ensure that the number of hours of training provided 
     by States under the demonstration project with respect to 
     such core training competencies are not less than the number 
     of hours of training required under any applicable State or 
     Federal law or regulation.
       ``(2) Duration.--A demonstration project shall be conducted 
     under this subsection for not less than 3 years.
       ``(3) Core training competencies for personal or home care 
     aides.--
       ``(A) In general.--The core training competencies for 
     personal or home care aides described in this subparagraph 
     include competencies with respect to the following areas:
       ``(i) The role of the personal or home care aide (including 
     differences between a personal or home care aide employed by 
     an agency and a personal or home care aide employed directly 
     by the health care consumer or an independent provider).
       ``(ii) Consumer rights, ethics, and confidentiality 
     (including the role of proxy decision-makers in the case 
     where a health care consumer has impaired decision-making 
     capacity).
       ``(iii) Communication, cultural and linguistic competence 
     and sensitivity, problem solving, behavior management, and 
     relationship skills.
       ``(iv) Personal care skills.
       ``(v) Health care support.
       ``(vi) Nutritional support.
       ``(vii) Infection control.
       ``(viii) Safety and emergency training.
       ``(ix) Training specific to an individual consumer's needs 
     (including older individuals, younger individuals with 
     disabilities, individuals with developmental disabilities, 
     individuals with dementia, and individuals with mental and 
     behavioral health needs).
       ``(x) Self-Care.
       ``(B) Implementation.--The implementation issues specified 
     in this subparagraph include the following:
       ``(i) The length of the training.
       ``(ii) The appropriate trainer to student ratio.
       ``(iii) The amount of instruction time spent in the 
     classroom as compared to on-site in the home or a facility.
       ``(iv) Trainer qualifications.
       ``(v) Content for a `hands-on' and written certification 
     exam.
       ``(vi) Continuing education requirements.
       ``(4) Application and selection criteria.--
       ``(A) In general.--
       ``(i) Number of states.--The Secretary shall enter into 
     agreements with not more than 6 States to conduct 
     demonstration projects under this subsection.
       ``(ii) Requirements for states.--An agreement entered into 
     under clause (i) shall require that a participating State--

       ``(I) implement the core training competencies described in 
     paragraph (3)(A); and
       ``(II) develop written materials and protocols for such 
     core training competencies, including the development of a 
     certification test for personal or home care aides who have 
     completed such training competencies.

       ``(iii) Consultation and collaboration with community and 
     vocational colleges.--The Secretary shall encourage 
     participating States to consult with community and vocational 
     colleges regarding the development of curricula to implement 
     the project with respect to activities, as applicable, which 
     may include consideration of such colleges as partners in 
     such implementation.
       ``(B) Application and eligibility.--A State seeking to 
     participate in the project shall--
       ``(i) submit an application to the Secretary containing 
     such information and at such time as the Secretary may 
     specify;
       ``(ii) meet the selection criteria established under 
     subparagraph (C); and
       ``(iii) meet such additional criteria as the Secretary may 
     specify.
       ``(C) Selection criteria.--In selecting States to 
     participate in the program, the Secretary shall establish 
     criteria to ensure (if applicable with respect to the 
     activities involved)--
       ``(i) geographic and demographic diversity;
       ``(ii) that participating States offer medical assistance 
     for personal care services under the State Medicaid plan;
       ``(iii) that the existing training standards for personal 
     or home care aides in each participating State--

       ``(I) are different from such standards in the other 
     participating States; and
       ``(II) are different from the core training competencies 
     described in paragraph (3)(A);

       ``(iv) that participating States do not reduce the number 
     of hours of training required under applicable State law or 
     regulation after being selected to participate in the 
     project; and
       ``(v) that participating States recruit a minimum number of 
     eligible health and long-term care providers to participate 
     in the project.
       ``(D) Technical assistance.--The Secretary shall provide 
     technical assistance to States in developing written 
     materials and protocols for such core training competencies.
       ``(5) Evaluation and report.--
       ``(A) Evaluation.--The Secretary shall develop an 
     experimental or control group testing protocol in 
     consultation with an independent evaluation contractor 
     selected by the Secretary. Such contractor shall evaluate--
       ``(i) the impact of core training competencies described in 
     paragraph (3)(A), including curricula developed to implement 
     such core training competencies, for personal or home care 
     aides within each participating State on job satisfaction, 
     mastery of job skills, beneficiary and family caregiver 
     satisfaction with services, and additional measures 
     determined by the Secretary in consultation with the expert 
     panel;
       ``(ii) the impact of providing such core training 
     competencies on the existing training infrastructure and 
     resources of States; and
       ``(iii) whether a minimum number of hours of initial 
     training should be required for personal or home care aides 
     and, if so, what minimum number of hours should be required.
       ``(B) Reports.--
       ``(i) Report on initial implementation.--Not later than 2 
     years after the date of enactment of this section, the 
     Secretary shall submit

[[Page 4350]]

     to Congress a report on the initial implementation of 
     activities conducted under the demonstration project, 
     including any available results of the evaluation conducted 
     under subparagraph (A) with respect to such activities, 
     together with such recommendations for legislation or 
     administrative action as the Secretary determines 
     appropriate.
       ``(ii) Final report.--Not later than 1 year after the 
     completion of the demonstration project, the Secretary shall 
     submit to Congress a report containing the results of the 
     evaluation conducted under subparagraph (A), together with 
     such recommendations for legislation or administrative action 
     as the Secretary determines appropriate.
       ``(6) Definitions.--In this subsection:
       ``(A) Eligible health and long-term care provider.--The 
     term `eligible health and long-term care provider' means a 
     personal or home care agency (including personal or home care 
     public authorities), a nursing home, a home health agency (as 
     defined in section 1861(o)), or any other health care 
     provider the Secretary determines appropriate which--
       ``(i) is licensed or authorized to provide services in a 
     participating State; and
       ``(ii) receives payment for services under title XIX.
       ``(B) Personal care services.--The term `personal care 
     services' has the meaning given such term for purposes of 
     title XIX.
       ``(C) Personal or home care aide.--The term `personal or 
     home care aide' means an individual who helps individuals who 
     are elderly, disabled, ill, or mentally disabled (including 
     an individual with Alzheimer's disease or other dementia) to 
     live in their own home or a residential care facility (such 
     as a nursing home, assisted living facility, or any other 
     facility the Secretary determines appropriate) by providing 
     routine personal care services and other appropriate services 
     to the individual.
       ``(D) State.--The term `State' has the meaning given that 
     term for purposes of title XIX.
       ``(c) Funding.--
       ``(1) In general.--Subject to paragraph (2), out of any 
     funds in the Treasury not otherwise appropriated, there are 
     appropriated to the Secretary to carry out subsections (a) 
     and (b), $85,000,000 for each of fiscal years 2010 through 
     2014.
       ``(2) Training and certification programs for personal and 
     home care aides.--With respect to the demonstration projects 
     under subsection (b), the Secretary shall use $5,000,000 of 
     the amount appropriated under paragraph (1) for each of 
     fiscal years 2010 through 2012 to carry out such projects. No 
     funds appropriated under paragraph (1) shall be used to carry 
     out demonstration projects under subsection (b) after fiscal 
     year 2012.
       ``(d) Nonapplication.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     preceding sections of this title shall not apply to grant 
     awarded under this section.
       ``(2) Limitations on use of grants.--Section 2005(a) (other 
     than paragraph (6)) shall apply to a grant awarded under this 
     section to the same extent and in the same manner as such 
     section applies to payments to States under this title.''.
       (b) Extension of Family-To-Family Health Information 
     Centers.--Section 501(c)(1)(A)(iii) of the Social Security 
     Act (42 U.S.C. 701(c)(1)(A)(iii)) is amended by striking 
     ``fiscal year 2009'' and inserting ``each of fiscal years 
     2009 through 2012''.

     SEC. 5508. INCREASING TEACHING CAPACITY.

       (a) Teaching Health Centers Training and Enhancement.--Part 
     C of title VII of the Public Health Service Act (42 U.S.C. 
     293k et. seq.), as amended by section 5303, is further 
     amended by inserting after section 749 the following:

     ``SEC. 749A. TEACHING HEALTH CENTERS DEVELOPMENT GRANTS.

       ``(a) Program Authorized.--The Secretary may award grants 
     under this section to teaching health centers for the purpose 
     of establishing new accredited or expanded primary care 
     residency programs.
       ``(b) Amount and Duration.--Grants awarded under this 
     section shall be for a term of not more than 3 years and the 
     maximum award may not be more than $500,000.
       ``(c) Use of Funds.--Amounts provided under a grant under 
     this section shall be used to cover the costs of--
       ``(1) establishing or expanding a primary care residency 
     training program described in subsection (a), including costs 
     associated with--
       ``(A) curriculum development;
       ``(B) recruitment, training and retention of residents and 
     faculty:
       ``(C) accreditation by the Accreditation Council for 
     Graduate Medical Education (ACGME), the American Dental 
     Association (ADA), or the American Osteopathic Association 
     (AOA); and
       ``(D) faculty salaries during the development phase; and
       ``(2) technical assistance provided by an eligible entity.
       ``(d) Application.--A teaching health center seeking a 
     grant under this section shall submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(e) Preference for Certain Applications.--In selecting 
     recipients for grants under this section, the Secretary shall 
     give preference to any such application that documents an 
     existing affiliation agreement with an area health education 
     center program as defined in sections 751 and 799B.
       ``(f) Definitions.--In this section:
       ``(1) Eligible entity.--The term `eligible entity' means an 
     organization capable of providing technical assistance 
     including an area health education center program as defined 
     in sections 751 and 799B.
       ``(2) Primary care residency program.--The term `primary 
     care residency program' means an approved graduate medical 
     residency training program (as defined in section 340H) in 
     family medicine, internal medicine, pediatrics, internal 
     medicine-pediatrics, obstetrics and gynecology, psychiatry, 
     general dentistry, pediatric dentistry, and geriatrics.
       ``(3) Teaching health center.--
       ``(A) In general.--The term `teaching health center' means 
     an entity that--
       ``(i) is a community based, ambulatory patient care center; 
     and
       ``(ii) operates a primary care residency program.
       ``(B) Inclusion of certain entities.--Such term includes 
     the following:
       ``(i) A Federally qualified health center (as defined in 
     section 1905(l)(2)(B), of the Social Security Act).
       ``(ii) A community mental health center (as defined in 
     section 1861(ff)(3)(B) of the Social Security Act).
       ``(iii) A rural health clinic, as defined in section 
     1861(aa) of the Social Security Act.
       ``(iv) A health center operated by the Indian Health 
     Service, an Indian tribe or tribal organization, or an urban 
     Indian organization (as defined in section 4 of the Indian 
     Health Care Improvement Act).
       ``(v) An entity receiving funds under title X of the Public 
     Health Service Act.
       ``(g) Authorization of Appropriations.--There is authorized 
     to be appropriated, $25,000,000 for fiscal year 2010, 
     $50,000,000 for fiscal year 2011, $50,000,000 for fiscal year 
     2012, and such sums as may be necessary for each fiscal year 
     thereafter to carry out this section. Not to exceed 
     $5,000,000 annually may be used for technical assistance 
     program grants.''.
       (b) National Health Service Corps Teaching Capacity.--
     Section 338C(a) of the Public Health Service Act (42 U.S.C. 
     254m(a)) is amended to read as follows:
       ``(a) Service in Full-time Clinical Practice.--Except as 
     provided in section 338D, each individual who has entered 
     into a written contract with the Secretary under section 338A 
     or 338B shall provide service in the full-time clinical 
     practice of such individual's profession as a member of the 
     Corps for the period of obligated service provided in such 
     contract. For the purpose of calculating time spent in full-
     time clinical practice under this subsection, up to 50 
     percent of time spent teaching by a member of the Corps may 
     be counted toward his or her service obligation.''.
       (c) Payments to Qualified Teaching Health Centers.--Part D 
     of title III of the Public Health Service Act (42 U.S.C. 254b 
     et seq.) is amended by adding at the end the following:

   ``Subpart XI--Support of Graduate Medical Education in Qualified 
                        Teaching Health Centers

     ``SEC. 340H. PROGRAM OF PAYMENTS TO TEACHING HEALTH CENTERS 
                   THAT OPERATE GRADUATE MEDICAL EDUCATION 
                   PROGRAMS.

       ``(a) Payments.--Subject to subsection (h)(2), the 
     Secretary shall make payments under this section for direct 
     expenses and for indirect expenses to qualified teaching 
     health centers that are listed as sponsoring institutions by 
     the relevant accrediting body for expansion of existing or 
     establishment of new approved graduate medical residency 
     training programs.
       ``(b) Amount of Payments.--
       ``(1) In general.--Subject to paragraph (2), the amounts 
     payable under this section to qualified teaching health 
     centers for an approved graduate medical residency training 
     program for a fiscal year are each of the following amounts:
       ``(A) Direct expense amount.--The amount determined under 
     subsection (c) for direct expenses associated with sponsoring 
     approved graduate medical residency training programs.
       ``(B) Indirect expense amount.--The amount determined under 
     subsection (d) for indirect expenses associated with the 
     additional costs relating to teaching residents in such 
     programs.
       ``(2) Capped amount.--
       ``(A) In general.--The total of the payments made to 
     qualified teaching health centers under paragraph (1)(A) or 
     paragraph (1)(B) in a fiscal year shall not exceed the amount 
     of funds appropriated under subsection (g) for such payments 
     for that fiscal year.
       ``(B) Limitation.--The Secretary shall limit the funding of 
     full-time equivalent residents in order to ensure the direct 
     and indirect payments as determined under subsection (c) and 
     (d) do not exceed the total amount of funds appropriated in a 
     fiscal year under subsection (g).
       ``(c) Amount of Payment for Direct Graduate Medical 
     Education.--
       ``(1) In general.--The amount determined under this 
     subsection for payments to qualified teaching health centers 
     for direct graduate expenses relating to approved graduate 
     medical residency training programs for a fiscal year is 
     equal to the product of--
       ``(A) the updated national per resident amount for direct 
     graduate medical education, as determined under paragraph 
     (2); and
       ``(B) the average number of full-time equivalent residents 
     in the teaching health center's graduate approved medical 
     residency training programs as determined under section 
     1886(h)(4) of the Social Security Act (without regard to the 
     limitation under subparagraph (F) of such section) during the 
     fiscal year.
       ``(2) Updated national per resident amount for direct 
     graduate medical education.--The updated per resident amount 
     for

[[Page 4351]]

     direct graduate medical education for a qualified teaching 
     health center for a fiscal year is an amount determined as 
     follows:
       ``(A) Determination of qualified teaching health center per 
     resident amount.--The Secretary shall compute for each 
     individual qualified teaching health center a per resident 
     amount--
       ``(i) by dividing the national average per resident amount 
     computed under section 340E(c)(2)(D) into a wage-related 
     portion and a non-wage related portion by applying the 
     proportion determined under subparagraph (B);
       ``(ii) by multiplying the wage-related portion by the 
     factor applied under section 1886(d)(3)(E) of the Social 
     Security Act (but without application of section 4410 of the 
     Balanced Budget Act of 1997 (42 U.S.C. 1395ww note)) during 
     the preceding fiscal year for the teaching health center's 
     area; and
       ``(iii) by adding the non-wage-related portion to the 
     amount computed under clause (ii).
       ``(B) Updating rate.--The Secretary shall update such per 
     resident amount for each such qualified teaching health 
     center as determined appropriate by the Secretary.
       ``(d) Amount of Payment for Indirect Medical Education.--
       ``(1) In general.--The amount determined under this 
     subsection for payments to qualified teaching health centers 
     for indirect expenses associated with the additional costs of 
     teaching residents for a fiscal year is equal to an amount 
     determined appropriate by the Secretary.
       ``(2) Factors.--In determining the amount under paragraph 
     (1), the Secretary shall--
       ``(A) evaluate indirect training costs relative to 
     supporting a primary care residency program in qualified 
     teaching health centers; and
       ``(B) based on this evaluation, assure that the aggregate 
     of the payments for indirect expenses under this section and 
     the payments for direct graduate medical education as 
     determined under subsection (c) in a fiscal year do not 
     exceed the amount appropriated for such expenses as 
     determined in subsection (g).
       ``(3) Interim payment.--Before the Secretary makes a 
     payment under this subsection pursuant to a determination of 
     indirect expenses under paragraph (1), the Secretary may 
     provide to qualified teaching health centers a payment, in 
     addition to any payment made under subsection (c), for 
     expected indirect expenses associated with the additional 
     costs of teaching residents for a fiscal year, based on an 
     estimate by the Secretary.
       ``(e) Clarification Regarding Relationship to Other 
     Payments for Graduate Medical Education.--Payments under this 
     section--
       ``(1) shall be in addition to any payments--
       ``(A) for the indirect costs of medical education under 
     section 1886(d)(5)(B) of the Social Security Act;
       ``(B) for direct graduate medical education costs under 
     section 1886(h) of such Act; and
       ``(C) for direct costs of medical education under section 
     1886(k) of such Act;
       ``(2) shall not be taken into account in applying the 
     limitation on the number of total full-time equivalent 
     residents under subparagraphs (F) and (G) of section 
     1886(h)(4) of such Act and clauses (v), (vi)(I), and (vi)(II) 
     of section 1886(d)(5)(B) of such Act for the portion of time 
     that a resident rotates to a hospital; and
       ``(3) shall not include the time in which a resident is 
     counted toward full-time equivalency by a hospital under 
     paragraph (2) or under section 1886(d)(5)(B)(iv) of the 
     Social Security Act, section 1886(h)(4)(E) of such Act, or 
     section 340E of this Act.
       ``(f) Reconciliation.--The Secretary shall determine any 
     changes to the number of residents reported by a hospital in 
     the application of the hospital for the current fiscal year 
     to determine the final amount payable to the hospital for the 
     current fiscal year for both direct expense and indirect 
     expense amounts. Based on such determination, the Secretary 
     shall recoup any overpayments made to pay any balance due to 
     the extent possible. The final amount so determined shall be 
     considered a final intermediary determination for the 
     purposes of section 1878 of the Social Security Act and shall 
     be subject to administrative and judicial review under that 
     section in the same manner as the amount of payment under 
     section 1186(d) of such Act is subject to review under such 
     section.
       ``(g) Funding.--To carry out this section, there are 
     appropriated such sums as may be necessary, not to exceed 
     $230,000,000, for the period of fiscal years 2011 through 
     2015.
       ``(h) Annual Reporting Required.--
       ``(1) Annual report.--The report required under this 
     paragraph for a qualified teaching health center for a fiscal 
     year is a report that includes (in a form and manner 
     specified by the Secretary) the following information for the 
     residency academic year completed immediately prior to such 
     fiscal year:
       ``(A) The types of primary care resident approved training 
     programs that the qualified teaching health center provided 
     for residents.
       ``(B) The number of approved training positions for 
     residents described in paragraph (4).
       ``(C) The number of residents described in paragraph (4) 
     who completed their residency training at the end of such 
     residency academic year and care for vulnerable populations 
     living in underserved areas.
       ``(D) Other information as deemed appropriate by the 
     Secretary.
       ``(2) Audit authority; limitation on payment.--
       ``(A) Audit authority.--The Secretary may audit a qualified 
     teaching health center to ensure the accuracy and 
     completeness of the information submitted in a report under 
     paragraph (1).
       ``(B) Limitation on payment.--A teaching health center may 
     only receive payment in a cost reporting period for a number 
     of such resident positions that is greater than the base 
     level of primary care resident positions, as determined by 
     the Secretary. For purposes of this subparagraph, the `base 
     level of primary care residents' for a teaching health center 
     is the level of such residents as of a base period.
       ``(3) Reduction in payment for failure to report.--
       ``(A) In general.--The amount payable under this section to 
     a qualified teaching health center for a fiscal year shall be 
     reduced by at least 25 percent if the Secretary determines 
     that--
       ``(i) the qualified teaching health center has failed to 
     provide the Secretary, as an addendum to the qualified 
     teaching health center's application under this section for 
     such fiscal year, the report required under paragraph (1) for 
     the previous fiscal year; or
       ``(ii) such report fails to provide complete and accurate 
     information required under any subparagraph of such 
     paragraph.
       ``(B) Notice and opportunity to provide accurate and 
     missing information.--Before imposing a reduction under 
     subparagraph (A) on the basis of a qualified teaching health 
     center's failure to provide complete and accurate information 
     described in subparagraph (A)(ii), the Secretary shall 
     provide notice to the teaching health center of such failure 
     and the Secretary's intention to impose such reduction and 
     shall provide the teaching health center with the opportunity 
     to provide the required information within the period of 30 
     days beginning on the date of such notice. If the teaching 
     health center provides such information within such period, 
     no reduction shall be made under subparagraph (A) on the 
     basis of the previous failure to provide such information.
       ``(4) Residents.--The residents described in this paragraph 
     are those who are in part-time or full-time equivalent 
     resident training positions at a qualified teaching health 
     center in any approved graduate medical residency training 
     program.
       ``(i) Regulations.--The Secretary shall promulgate 
     regulations to carry out this section.
       ``(j) Definitions.--In this section:
       ``(1) Approved graduate medical residency training 
     program.--The term `approved graduate medical residency 
     training program' means a residency or other postgraduate 
     medical training program--
       ``(A) participation in which may be counted toward 
     certification in a specialty or subspecialty and includes 
     formal postgraduate training programs in geriatric medicine 
     approved by the Secretary; and
       ``(B) that meets criteria for accreditation (as established 
     by the Accreditation Council for Graduate Medical Education, 
     the American Osteopathic Association, or the American Dental 
     Association).
       ``(2) Primary care residency program.--The term `primary 
     care residency program' has the meaning given that term in 
     section 749A.
       ``(3) Qualified teaching health center.--The term 
     `qualified teaching health center' has the meaning given the 
     term `teaching health center' in section 749A.''.

     SEC. 5509. GRADUATE NURSE EDUCATION DEMONSTRATION.

       (a) In General.--
       (1) Establishment.--
       (A) In general.--The Secretary shall establish a graduate 
     nurse education demonstration under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.) under which an eligible 
     hospital may receive payment for the hospital's reasonable 
     costs (described in paragraph (2)) for the provision of 
     qualified clinical training to advance practice nurses.
       (B) Number.--The demonstration shall include up to 5 
     eligible hospitals.
       (C) Written agreements.--Eligible hospitals selected to 
     participate in the demonstration shall enter into written 
     agreements pursuant to subsection (b) in order to reimburse 
     the eligible partners of the hospital the share of the costs 
     attributable to each partner.
       (2) Costs described.--
       (A) In general.--Subject to subparagraph (B) and subsection 
     (d), the costs described in this paragraph are the reasonable 
     costs (as described in section 1861(v) of the Social Security 
     Act (42 U.S.C. 1395x(v))) of each eligible hospital for the 
     clinical training costs (as determined by the Secretary) that 
     are attributable to providing advanced practice registered 
     nurses with qualified training.
       (B) Limitation.--With respect to a year, the amount 
     reimbursed under subparagraph (A) may not exceed the amount 
     of costs described in subparagraph (A) that are attributable 
     to an increase in the number of advanced practice registered 
     nurses enrolled in a program that provides qualified training 
     during the year and for which the hospital is being 
     reimbursed under the demonstration, as compared to the 
     average number of advanced practice registered nurses who 
     graduated in each year during the period beginning on January 
     1, 2006, and ending on December 31, 2010 (as determined by 
     the Secretary) from the graduate nursing education program 
     operated by the applicable school of nursing that is an 
     eligible partner of the hospital for purposes of the 
     demonstration.
       (3) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act as may be necessary to carry out the demonstration.
       (4) Administration.--Chapter 35 of title 44, United States 
     Code, shall not apply to the implementation of this section.

[[Page 4352]]

       (b) Written Agreements With Eligible Partners.--No payment 
     shall be made under this section to an eligible hospital 
     unless such hospital has in effect a written agreement with 
     the eligible partners of the hospital. Such written agreement 
     shall describe, at a minimum--
       (1) the obligations of the eligible partners with respect 
     to the provision of qualified training; and
       (2) the obligation of the eligible hospital to reimburse 
     such eligible partners applicable (in a timely manner) for 
     the costs of such qualified training attributable to partner.
       (c) Evaluation.--Not later than October 17, 2017, the 
     Secretary shall submit to Congress a report on the 
     demonstration. Such report shall include an analysis of the 
     following:
       (1) The growth in the number of advanced practice 
     registered nurses with respect to a specific base year as a 
     result of the demonstration.
       (2) The growth for each of the specialties described in 
     subparagraphs (A) through (D) of subsection (e)(1).
       (3) The costs to the Medicare program under title XVIII of 
     the Social Security Act as a result of the demonstration.
       (4) Other items the Secretary determines appropriate and 
     relevant.
       (d) Funding.--
       (1) In general.--There is hereby appropriated to the 
     Secretary, out of any funds in the Treasury not otherwise 
     appropriated, $50,000,000 for each of fiscal years 2012 
     through 2015 to carry out this section, including the design, 
     implementation, monitoring, and evaluation of the 
     demonstration.
       (2) Proration.--If the aggregate payments to eligible 
     hospitals under the demonstration exceed $50,000,000 for a 
     fiscal year described in paragraph (1), the Secretary shall 
     prorate the payment amounts to each eligible hospital in 
     order to ensure that the aggregate payments do not exceed 
     such amount.
       (3) Without fiscal year limitation.--Amounts appropriated 
     under this subsection shall remain available without fiscal 
     year limitation.
       (e) Definitions.--In this section:
       (1) Advanced practice registered nurse.--The term 
     ``advanced practice registered nurse'' includes the 
     following:
       (A) A clinical nurse specialist (as defined in subsection 
     (aa)(5) of section 1861 of the Social Security Act (42 U.S.C. 
     1395x)).
       (B) A nurse practitioner (as defined in such subsection).
       (C) A certified registered nurse anesthetist (as defined in 
     subsection (bb)(2) of such section).
       (D) A certified nurse-midwife (as defined in subsection 
     (gg)(2) of such section).
       (2) Applicable non-hospital community-based care setting.--
     The term ``applicable non-hospital community-based care 
     setting'' means a non-hospital community-based care setting 
     which has entered into a written agreement (as described in 
     subsection (b)) with the eligible hospital participating in 
     the demonstration. Such settings include Federally qualified 
     health centers, rural health clinics, and other non-hospital 
     settings as determined appropriate by the Secretary.
       (3) Applicable school of nursing.--The term ``applicable 
     school of nursing'' means an accredited school of nursing (as 
     defined in section 801 of the Public Health Service Act) 
     which has entered into a written agreement (as described in 
     subsection (b)) with the eligible hospital participating in 
     the demonstration.
       (4) Demonstration.--The term ``demonstration'' means the 
     graduate nurse education demonstration established under 
     subsection (a).
       (5) Eligible hospital.--The term ``eligible hospital'' 
     means a hospital (as defined in subsection (e) of section 
     1861 of the Social Security Act (42 U.S.C. 1395x)) or a 
     critical access hospital (as defined in subsection (mm)(1) of 
     such section) that has a written agreement in place with--
       (A) 1 or more applicable schools of nursing; and
       (B) 2 or more applicable non-hospital community-based care 
     settings.
       (6) Eligible partners.--The term ``eligible partners'' 
     includes the following:
       (A) An applicable non-hospital community-based care 
     setting.
       (B) An applicable school of nursing.
       (7) Qualified training.--
       (A) In general.--The term ``qualified training'' means 
     training--
       (i) that provides an advanced practice registered nurse 
     with the clinical skills necessary to provide primary care, 
     preventive care, transitional care, chronic care management, 
     and other services appropriate for individuals entitled to, 
     or enrolled for, benefits under part A of title XVIII of the 
     Social Security Act, or enrolled under part B of such title; 
     and
       (ii) subject to subparagraph (B), at least half of which is 
     provided in a non-hospital community-based care setting.
       (B) Waiver of requirement half of training be provided in 
     non-hospital community-based care setting in certain areas.--
     The Secretary may waive the requirement under subparagraph 
     (A)(ii) with respect to eligible hospitals located in rural 
     or medically underserved areas.
       (8) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.

          Subtitle G--Improving Access to Health Care Services

     SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS 
                   (FQHCS).

       (a) In General.--Section 330(r) of the Public Health 
     Service Act (42 U.S.C. 254b(r)) is amended by striking 
     paragraph (1) and inserting the following:
       ``(1) General amounts for grants.--For the purpose of 
     carrying out this section, in addition to the amounts 
     authorized to be appropriated under subsection (d), there is 
     authorized to be appropriated the following:
       ``(A) For fiscal year 2010, $2,988,821,592.
       ``(B) For fiscal year 2011, $3,862,107,440.
       ``(C) For fiscal year 2012, $4,990,553,440.
       ``(D) For fiscal year 2013, $6,448,713,307.
       ``(E) For fiscal year 2014, $7,332,924,155.
       ``(F) For fiscal year 2015, $8,332,924,155.
       ``(G) For fiscal year 2016, and each subsequent fiscal 
     year, the amount appropriated for the preceding fiscal year 
     adjusted by the product of--
       ``(i) one plus the average percentage increase in costs 
     incurred per patient served; and
       ``(ii) one plus the average percentage increase in the 
     total number of patients served.''.
       (b) Rule of Construction.--Section 330(r) of the Public 
     Health Service Act (42 U.S.C. 254b(r)) is amended by adding 
     at the end the following:
       ``(4) Rule of construction with respect to rural health 
     clinics.--
       ``(A) In general.--Nothing in this section shall be 
     construed to prevent a community health center from 
     contracting with a Federally certified rural health clinic 
     (as defined in section 1861(aa)(2) of the Social Security 
     Act), a low-volume hospital (as defined for purposes of 
     section 1886 of such Act), a critical access hospital, a sole 
     community hospital (as defined for purposes of section 
     1886(d)(5)(D)(iii) of such Act), or a medicare-dependent 
     share hospital (as defined for purposes of section 
     1886(d)(5)(G)(iv) of such Act) for the delivery of primary 
     health care services that are available at the clinic or 
     hospital to individuals who would otherwise be eligible for 
     free or reduced cost care if that individual were able to 
     obtain that care at the community health center. Such 
     services may be limited in scope to those primary health care 
     services available in that clinic or hospitals.
       ``(B) Assurances.--In order for a clinic or hospital to 
     receive funds under this section through a contract with a 
     community health center under subparagraph (A), such clinic 
     or hospital shall establish policies to ensure--
       ``(i) nondiscrimination based on the ability of a patient 
     to pay; and
       ``(ii) the establishment of a sliding fee scale for low-
     income patients.''.

     SEC. 5602. NEGOTIATED RULEMAKING FOR DEVELOPMENT OF 
                   METHODOLOGY AND CRITERIA FOR DESIGNATING 
                   MEDICALLY UNDERSERVED POPULATIONS AND HEALTH 
                   PROFESSIONS SHORTAGE AREAS.

       (a) Establishment.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish, through a negotiated rulemaking process under 
     subchapter 3 of chapter 5 of title 5, United States Code, a 
     comprehensive methodology and criteria for designation of--
       (A) medically underserved populations in accordance with 
     section 330(b)(3) of the Public Health Service Act (42 U.S.C. 
     254b(b)(3));
       (B) health professions shortage areas under section 332 of 
     the Public Health Service Act (42 U.S.C. 254e).
       (2) Factors to consider.--In establishing the methodology 
     and criteria under paragraph (1), the Secretary--
       (A) shall consult with relevant stakeholders who will be 
     significantly affected by a rule (such as national, State and 
     regional organizations representing affected entities), State 
     health offices, community organizations, health centers and 
     other affected entities, and other interested parties; and
       (B) shall take into account--
       (i) the timely availability and appropriateness of data 
     used to determine a designation to potential applicants for 
     such designations;
       (ii) the impact of the methodology and criteria on 
     communities of various types and on health centers and other 
     safety net providers;
       (iii) the degree of ease or difficulty that will face 
     potential applicants for such designations in securing the 
     necessary data; and
       (iv) the extent to which the methodology accurately 
     measures various barriers that confront individuals and 
     population groups in seeking health care services.
       (b) Publication of Notice.--In carrying out the rulemaking 
     process under this subsection, the Secretary shall publish 
     the notice provided for under section 564(a) of title 5, 
     United States Code, by not later than 45 days after the date 
     of the enactment of this Act.
       (c) Target Date for Publication of Rule.--As part of the 
     notice under subsection (b), and for purposes of this 
     subsection, the ``target date for publication'', as referred 
     to in section 564(a)(5) of title 5, United Sates Code, shall 
     be July 1, 2010.
       (d) Appointment of Negotiated Rulemaking Committee and 
     Facilitator.--The Secretary shall provide for--
       (1) the appointment of a negotiated rulemaking committee 
     under section 565(a) of title 5, United States Code, by not 
     later than 30 days after the end of the comment period 
     provided for under section 564(c) of such title; and
       (2) the nomination of a facilitator under section 566(c) of 
     such title 5 by not later than 10 days after the date of 
     appointment of the committee.
       (e) Preliminary Committee Report.--The negotiated 
     rulemaking committee appointed under subsection (d) shall 
     report to the Secretary, by not later than April 1, 2010, 
     regarding the committee's progress on achieving a consensus 
     with regard to the rulemaking proceeding

[[Page 4353]]

     and whether such consensus is likely to occur before one 
     month before the target date for publication of the rule. If 
     the committee reports that the committee has failed to make 
     significant progress toward such consensus or is unlikely to 
     reach such consensus by the target date, the Secretary may 
     terminate such process and provide for the publication of a 
     rule under this section through such other methods as the 
     Secretary may provide.
       (f) Final Committee Report.--If the committee is not 
     terminated under subsection (e), the rulemaking committee 
     shall submit a report containing a proposed rule by not later 
     than one month before the target publication date.
       (g) Interim Final Effect.--The Secretary shall publish a 
     rule under this section in the Federal Register by not later 
     than the target publication date. Such rule shall be 
     effective and final immediately on an interim basis, but is 
     subject to change and revision after public notice and 
     opportunity for a period (of not less than 90 days) for 
     public comment. In connection with such rule, the Secretary 
     shall specify the process for the timely review and approval 
     of applications for such designations pursuant to such rules 
     and consistent with this section.
       (h) Publication of Rule After Public Comment.--The 
     Secretary shall provide for consideration of such comments 
     and republication of such rule by not later than 1 year after 
     the target publication date.

     SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MEDICAL 
                   SERVICES FOR CHILDREN PROGRAM.

       Section 1910 of the Public Health Service Act (42 U.S.C. 
     300w-9) is amended--
       (1) in subsection (a), by striking ``3-year period (with an 
     optional 4th year'' and inserting ``4-year period (with an 
     optional 5th year''; and
       (2) in subsection (d)--
       (A) by striking ``and such sums'' and inserting ``such 
     sums''; and
       (B) by inserting before the period the following: ``, 
     $25,000,000 for fiscal year 2010, $26,250,000 for fiscal year 
     2011, $27,562,500 for fiscal year 2012, $28,940,625 for 
     fiscal year 2013, and $30,387,656 for fiscal year 2014''.

     SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN 
                   COMMUNITY-BASED MENTAL HEALTH SETTINGS.

       Subpart 3 of part B of title V of the Public Health Service 
     Act (42 U.S.C. 290bb-31 et seq.) is amended by adding at the 
     end the following:

     ``SEC. 520K. AWARDS FOR CO-LOCATING PRIMARY AND SPECIALTY 
                   CARE IN COMMUNITY-BASED MENTAL HEALTH SETTINGS.

       ``(a) Definitions.--In this section:
       ``(1) Eligible entity.--The term `eligible entity' means a 
     qualified community mental health program defined under 
     section 1913(b)(1).
       ``(2) Special populations.--The term `special populations' 
     means adults with mental illnesses who have co-occurring 
     primary care conditions and chronic diseases.
       ``(b) Program Authorized.--The Secretary, acting through 
     the Administrator shall award grants and cooperative 
     agreements to eligible entities to establish demonstration 
     projects for the provision of coordinated and integrated 
     services to special populations through the co-location of 
     primary and specialty care services in community-based mental 
     and behavioral health settings.
       ``(c) Application.--To be eligible to receive a grant or 
     cooperative agreement under this section, an eligible entity 
     shall submit an application to the Administrator at such 
     time, in such manner, and accompanied by such information as 
     the Administrator may require, including a description of 
     partnerships, or other arrangements with local primary care 
     providers, including community health centers, to provide 
     services to special populations.
       ``(d) Use of Funds.--
       ``(1) In general.--For the benefit of special populations, 
     an eligible entity shall use funds awarded under this section 
     for--
       ``(A) the provision, by qualified primary care 
     professionals, of on site primary care services;
       ``(B) reasonable costs associated with medically necessary 
     referrals to qualified specialty care professionals, other 
     coordinators of care or, if permitted by the terms of the 
     grant or cooperative agreement, by qualified specialty care 
     professionals on a reasonable cost basis on site at the 
     eligible entity;
       ``(C) information technology required to accommodate the 
     clinical needs of primary and specialty care professionals; 
     or
       ``(D) facility modifications needed to bring primary and 
     specialty care professionals on site at the eligible entity.
       ``(2) Limitation.--Not to exceed 15 percent of grant or 
     cooperative agreement funds may be used for activities 
     described in subparagraphs (C) and (D) of paragraph (1).
       ``(e) Evaluation.--Not later than 90 days after a grant or 
     cooperative agreement awarded under this section expires, an 
     eligible entity shall submit to the Secretary the results of 
     an evaluation to be conducted by the entity concerning the 
     effectiveness of the activities carried out under the grant 
     or agreement.
       ``(f) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $50,000,000 for fiscal year 2010 and such sums as may be 
     necessary for each of fiscal years 2011 through 2014.''.

     SEC. 5605. KEY NATIONAL INDICATORS.

       (a) Definitions.--In this section:
       (1) Academy.--The term ``Academy'' means the National 
     Academy of Sciences.
       (2) Commission.--The term ``Commission'' means the 
     Commission on Key National Indicators established under 
     subsection (b).
       (3) Institute.--The term ``Institute'' means a Key National 
     Indicators Institute as designated under subsection (c)(3).
       (b) Commission on Key National Indicators.--
       (1) Establishment.--There is established a ``Commission on 
     Key National Indicators''.
       (2) Membership.--
       (A) Number and appointment.--The Commission shall be 
     composed of 8 members, to be appointed equally by the 
     majority and minority leaders of the Senate and the Speaker 
     and minority leader of the House of Representatives.
       (B) Prohibited appointments.--Members of the Commission 
     shall not include Members of Congress or other elected 
     Federal, State, or local government officials.
       (C) Qualifications.--In making appointments under 
     subparagraph (A), the majority and minority leaders of the 
     Senate and the Speaker and minority leader of the House of 
     Representatives shall appoint individuals who have shown a 
     dedication to improving civic dialogue and decision-making 
     through the wide use of scientific evidence and factual 
     information.
       (D) Period of appointment.--Each member of the Commission 
     shall be appointed for a 2-year term, except that 1 initial 
     appointment shall be for 3 years. Any vacancies shall not 
     affect the power and duties of the Commission but shall be 
     filled in the same manner as the original appointment and 
     shall last only for the remainder of that term.
       (E) Date.--Members of the Commission shall be appointed by 
     not later than 30 days after the date of enactment of this 
     Act.
       (F) Initial organizing period.---Not later than 60 days 
     after the date of enactment of this Act, the Commission shall 
     develop and implement a schedule for completion of the review 
     and reports required under subsection (d).
       (G) Co-chairpersons.--The Commission shall select 2 Co-
     Chairpersons from among its members.
       (c) Duties of the Commission.--
       (1) In general.--The Commission shall--
       (A) conduct comprehensive oversight of a newly established 
     key national indicators system consistent with the purpose 
     described in this subsection;
       (B) make recommendations on how to improve the key national 
     indicators system;
       (C) coordinate with Federal Government users and 
     information providers to assure access to relevant and 
     quality data; and
       (D) enter into contracts with the Academy.
       (2) Reports.--
       (A) Annual report to congress.--Not later than 1 year after 
     the selection of the 2 Co-Chairpersons of the Commission, and 
     each subsequent year thereafter, the Commission shall prepare 
     and submit to the appropriate Committees of Congress and the 
     President a report that contains a detailed statement of the 
     recommendations, findings, and conclusions of the Commission 
     on the activities of the Academy and a designated Institute 
     related to the establishment of a Key National Indicator 
     System.
       (B) Annual report to the academy.--
       (i) In general.--Not later than 6 months after the 
     selection of the 2 Co-Chairpersons of the Commission, and 
     each subsequent year thereafter, the Commission shall prepare 
     and submit to the Academy and a designated Institute a report 
     making recommendations concerning potential issue areas and 
     key indicators to be included in the Key National Indicators.
       (ii) Limitation.--The Commission shall not have the 
     authority to direct the Academy or, if established, the 
     Institute, to adopt, modify, or delete any key indicators.
       (3) Contract with the national academy of sciences.--
       (A) In general.---As soon as practicable after the 
     selection of the 2 Co-Chairpersons of the Commission, the Co-
     Chairpersons shall enter into an arrangement with the 
     National Academy of Sciences under which the Academy shall--
       (i) review available public and private sector research on 
     the selection of a set of key national indicators;
       (ii) determine how best to establish a key national 
     indicator system for the United States, by either creating 
     its own institutional capability or designating an 
     independent private nonprofit organization as an Institute to 
     implement a key national indicator system;
       (iii) if the Academy designates an independent Institute 
     under clause (ii), provide scientific and technical advice to 
     the Institute and create an appropriate governance mechanism 
     that balances Academy involvement and the independence of the 
     Institute; and
       (iv) provide an annual report to the Commission addressing 
     scientific and technical issues related to the key national 
     indicator system and, if established, the Institute, and 
     governance of the Institute's budget and operations.
       (B) Participation.--In executing the arrangement under 
     subparagraph (A), the National Academy of Sciences shall 
     convene a multi-sector, multi-disciplinary process to define 
     major scientific and technical issues associated with 
     developing, maintaining, and evolving a Key National 
     Indicator System and, if an Institute is established, to 
     provide it with scientific and technical advice.
       (C) Establishment of a key national indicator system.--
       (i) In general.--In executing the arrangement under 
     subparagraph (A), the National Academy of Sciences shall 
     enable the establishment of a key national indicator system 
     by--

       (I) creating its own institutional capability; or
       (II) partnering with an independent private nonprofit 
     organization as an Institute to implement a key national 
     indicator system.

[[Page 4354]]

       (ii) Institute.--If the Academy designates an Institute 
     under clause (i)(II), such Institute shall be a non-profit 
     entity (as defined for purposes of section 501(c)(3) of the 
     Internal Revenue Code of 1986) with an educational mission, a 
     governance structure that emphasizes independence, and 
     characteristics that make such entity appropriate for 
     establishing a key national indicator system.
       (iii) Responsibilities.--Either the Academy or the 
     Institute designated under clause (i)(II) shall be 
     responsible for the following:

       (I) Identifying and selecting issue areas to be represented 
     by the key national indicators.
       (II) Identifying and selecting the measures used for key 
     national indicators within the issue areas under subclause 
     (I).
       (III) Identifying and selecting data to populate the key 
     national indicators described under subclause (II).
       (IV) Designing, publishing, and maintaining a public 
     website that contains a freely accessible database allowing 
     public access to the key national indicators.
       (V) Developing a quality assurance framework to ensure 
     rigorous and independent processes and the selection of 
     quality data.
       (VI) Developing a budget for the construction and 
     management of a sustainable, adaptable, and evolving key 
     national indicator system that reflects all Commission 
     funding of Academy and, if an Institute is established, 
     Institute activities.
       (VII) Reporting annually to the Commission regarding its 
     selection of issue areas, key indicators, data, and progress 
     toward establishing a web-accessible database.
       (VIII) Responding directly to the Commission in response to 
     any Commission recommendations and to the Academy regarding 
     any inquiries by the Academy.

       (iv) Governance.--Upon the establishment of a key national 
     indicator system, the Academy shall create an appropriate 
     governance mechanism that incorporates advisory and control 
     functions. If an Institute is designated under clause 
     (i)(II), the governance mechanism shall balance appropriate 
     Academy involvement and the independence of the Institute.
       (v) Modification and changes.--The Academy shall retain the 
     sole discretion, at any time, to alter its approach to the 
     establishment of a key national indicator system or, if an 
     Institute is designated under clause (i)(II), to alter any 
     aspect of its relationship with the Institute or to designate 
     a different non-profit entity to serve as the Institute.
       (vi) Construction.--Nothing in this section shall be 
     construed to limit the ability of the Academy or the 
     Institute designated under clause (i)(II) to receive private 
     funding for activities related to the establishment of a key 
     national indicator system.
       (D) Annual report.--As part of the arrangement under 
     subparagraph (A), the National Academy of Sciences shall, not 
     later than 270 days after the date of enactment of this Act, 
     and annually thereafter, submit to the Co-Chairpersons of the 
     Commission a report that contains the findings and 
     recommendations of the Academy.
       (d) Government Accountability Office Study and Report.--
       (1) GAO study.--The Comptroller General of the United 
     States shall conduct a study of previous work conducted by 
     all public agencies, private organizations, or foreign 
     countries with respect to best practices for a key national 
     indicator system. The study shall be submitted to the 
     appropriate authorizing committees of Congress.
       (2) GAO financial audit.--If an Institute is established 
     under this section, the Comptroller General shall conduct an 
     annual audit of the financial statements of the Institute, in 
     accordance with generally accepted government auditing 
     standards and submit a report on such audit to the Commission 
     and the appropriate authorizing committees of Congress.
       (3) GAO programmatic review.--The Comptroller General of 
     the United States shall conduct programmatic assessments of 
     the Institute established under this section as determined 
     necessary by the Comptroller General and report the findings 
     to the Commission and to the appropriate authorizing 
     committees of Congress.
       (e) Authorization of Appropriations.--
       (1) In general.---There are authorized to be appropriated 
     to carry out the purposes of this section, $10,000,000 for 
     fiscal year 2010, and $7,500,000 for each of fiscal year 2011 
     through 2018.
       (2) Availability.---Amounts appropriated under paragraph 
     (1) shall remain available until expended.

                     Subtitle H--General Provisions

     SEC. 5701. REPORTS.

       (a) Reports by Secretary of Health and Human Services.--On 
     an annual basis, the Secretary of Health and Human Services 
     shall submit to the appropriate Committees of Congress a 
     report on the activities carried out under the amendments 
     made by this title, and the effectiveness of such activities.
       (b) Reports by Recipients of Funds.--The Secretary of 
     Health and Human Services may require, as a condition of 
     receiving funds under the amendments made by this title, that 
     the entity receiving such award submit to such Secretary such 
     reports as the such Secretary may require on activities 
     carried out with such award, and the effectiveness of such 
     activities.

              TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY

         Subtitle A--Physician Ownership and Other Transparency

     SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE 
                   PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR 
                   HOSPITALS.

       (a) In General.--Section 1877 of the Social Security Act 
     (42 U.S.C. 1395nn) is amended--
       (1) in subsection (d)(2)--
       (A) in subparagraph (A), by striking ``and'' at the end;
       (B) in subparagraph (B), by striking the period at the end 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(C) in the case where the entity is a hospital, the 
     hospital meets the requirements of paragraph (3)(D).'';
       (2) in subsection (d)(3)--
       (A) in subparagraph (B), by striking ``and'' at the end;
       (B) in subparagraph (C), by striking the period at the end 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(D) the hospital meets the requirements described in 
     subsection (i)(1) not later than 18 months after the date of 
     the enactment of this subparagraph.''; and
       (3) by adding at the end the following new subsection:
       ``(i) Requirements for Hospitals To Qualify for Rural 
     Provider and Hospital Exception to Ownership or Investment 
     Prohibition.--
       ``(1) Requirements described.--For purposes of subsection 
     (d)(3)(D), the requirements described in this paragraph for a 
     hospital are as follows:
       ``(A) Provider agreement.--The hospital had--
       ``(i) physician ownership or investment on February 1, 
     2010; and
       ``(ii) a provider agreement under section 1866 in effect on 
     such date.
       ``(B) Limitation on expansion of facility capacity.--Except 
     as provided in paragraph (3), the number of operating rooms, 
     procedure rooms, and beds for which the hospital is licensed 
     at any time on or after the date of the enactment of this 
     subsection is no greater than the number of operating rooms, 
     procedure rooms, and beds for which the hospital is licensed 
     as of such date.
       ``(C) Preventing conflicts of interest.--
       ``(i) The hospital submits to the Secretary an annual 
     report containing a detailed description of--

       ``(I) the identity of each physician owner or investor and 
     any other owners or investors of the hospital; and
       ``(II) the nature and extent of all ownership and 
     investment interests in the hospital.

       ``(ii) The hospital has procedures in place to require that 
     any referring physician owner or investor discloses to the 
     patient being referred, by a time that permits the patient to 
     make a meaningful decision regarding the receipt of care, as 
     determined by the Secretary--

       ``(I) the ownership or investment interest, as applicable, 
     of such referring physician in the hospital; and
       ``(II) if applicable, any such ownership or investment 
     interest of the treating physician.

       ``(iii) The hospital does not condition any physician 
     ownership or investment interests either directly or 
     indirectly on the physician owner or investor making or 
     influencing referrals to the hospital or otherwise generating 
     business for the hospital.
       ``(iv) The hospital discloses the fact that the hospital is 
     partially owned or invested in by physicians--

       ``(I) on any public website for the hospital; and
       ``(II) in any public advertising for the hospital.

       ``(D) Ensuring bona fide investment.--
       ``(i) The percentage of the total value of the ownership or 
     investment interests held in the hospital, or in an entity 
     whose assets include the hospital, by physician owners or 
     investors in the aggregate does not exceed such percentage as 
     of the date of enactment of this subsection.
       ``(ii) Any ownership or investment interests that the 
     hospital offers to a physician owner or investor are not 
     offered on more favorable terms than the terms offered to a 
     person who is not a physician owner or investor.
       ``(iii) The hospital (or any owner or investor in the 
     hospital) does not directly or indirectly provide loans or 
     financing for any investment in the hospital by a physician 
     owner or investor.
       ``(iv) The hospital (or any owner or investor in the 
     hospital) does not directly or indirectly guarantee a loan, 
     make a payment toward a loan, or otherwise subsidize a loan, 
     for any individual physician owner or investor or group of 
     physician owners or investors that is related to acquiring 
     any ownership or investment interest in the hospital.
       ``(v) Ownership or investment returns are distributed to 
     each owner or investor in the hospital in an amount that is 
     directly proportional to the ownership or investment interest 
     of such owner or investor in the hospital.
       ``(vi) Physician owners and investors do not receive, 
     directly or indirectly, any guaranteed receipt of or right to 
     purchase other business interests related to the hospital, 
     including the purchase or lease of any property under the 
     control of other owners or investors in the hospital or 
     located near the premises of the hospital.
       ``(vii) The hospital does not offer a physician owner or 
     investor the opportunity to purchase or lease any property 
     under the control of the

[[Page 4355]]

     hospital or any other owner or investor in the hospital on 
     more favorable terms than the terms offered to an individual 
     who is not a physician owner or investor.
       ``(E) Patient safety.--
       ``(i) Insofar as the hospital admits a patient and does not 
     have any physician available on the premises to provide 
     services during all hours in which the hospital is providing 
     services to such patient, before admitting the patient--

       ``(I) the hospital discloses such fact to a patient; and
       ``(II) following such disclosure, the hospital receives 
     from the patient a signed acknowledgment that the patient 
     understands such fact.

       ``(ii) The hospital has the capacity to--

       ``(I) provide assessment and initial treatment for 
     patients; and
       ``(II) refer and transfer patients to hospitals with the 
     capability to treat the needs of the patient involved.

       ``(F) Limitation on application to certain converted 
     facilities.--The hospital was not converted from an 
     ambulatory surgical center to a hospital on or after the date 
     of enactment of this subsection.
       ``(2) Publication of information reported.--The Secretary 
     shall publish, and update on an annual basis, the information 
     submitted by hospitals under paragraph (1)(C)(i) on the 
     public Internet website of the Centers for Medicare & 
     Medicaid Services.
       ``(3) Exception to prohibition on expansion of facility 
     capacity.--
       ``(A) Process.--
       ``(i) Establishment.--The Secretary shall establish and 
     implement a process under which an applicable hospital (as 
     defined in subparagraph (E)) may apply for an exception from 
     the requirement under paragraph (1)(B).
       ``(ii) Opportunity for community input.--The process under 
     clause (i) shall provide individuals and entities in the 
     community in which the applicable hospital applying for an 
     exception is located with the opportunity to provide input 
     with respect to the application.
       ``(iii) Timing for implementation.--The Secretary shall 
     implement the process under clause (i) on August 1, 2011.
       ``(iv) Regulations.--Not later than July 1, 2011, the 
     Secretary shall promulgate regulations to carry out the 
     process under clause (i).
       ``(B) Frequency.--The process described in subparagraph (A) 
     shall permit an applicable hospital to apply for an exception 
     up to once every 2 years.
       ``(C) Permitted increase.--
       ``(i) In general.--Subject to clause (ii) and subparagraph 
     (D), an applicable hospital granted an exception under the 
     process described in subparagraph (A) may increase the number 
     of operating rooms, procedure rooms, and beds for which the 
     applicable hospital is licensed above the baseline number of 
     operating rooms, procedure rooms, and beds of the applicable 
     hospital (or, if the applicable hospital has been granted a 
     previous exception under this paragraph, above the number of 
     operating rooms, procedure rooms, and beds for which the 
     hospital is licensed after the application of the most recent 
     increase under such an exception).
       ``(ii) 100 percent increase limitation.--The Secretary 
     shall not permit an increase in the number of operating 
     rooms, procedure rooms, and beds for which an applicable 
     hospital is licensed under clause (i) to the extent such 
     increase would result in the number of operating rooms, 
     procedure rooms, and beds for which the applicable hospital 
     is licensed exceeding 200 percent of the baseline number of 
     operating rooms, procedure rooms, and beds of the applicable 
     hospital.
       ``(iii) Baseline number of operating rooms, procedure 
     rooms, and beds.--In this paragraph, the term `baseline 
     number of operating rooms, procedure rooms, and beds' means 
     the number of operating rooms, procedure rooms, and beds for 
     which the applicable hospital is licensed as of the date of 
     enactment of this subsection.
       ``(D) Increase limited to facilities on the main campus of 
     the hospital.--Any increase in the number of operating rooms, 
     procedure rooms, and beds for which an applicable hospital is 
     licensed pursuant to this paragraph may only occur in 
     facilities on the main campus of the applicable hospital.
       ``(E) Applicable hospital.--In this paragraph, the term 
     `applicable hospital' means a hospital--
       ``(i) that is located in a county in which the percentage 
     increase in the population during the most recent 5-year 
     period (as of the date of the application under subparagraph 
     (A)) is at least 150 percent of the percentage increase in 
     the population growth of the State in which the hospital is 
     located during that period, as estimated by Bureau of the 
     Census;
       ``(ii) whose annual percent of total inpatient admissions 
     that represent inpatient admissions under the program under 
     title XIX is equal to or greater than the average percent 
     with respect to such admissions for all hospitals located in 
     the county in which the hospital is located;
       ``(iii) that does not discriminate against beneficiaries of 
     Federal health care programs and does not permit physicians 
     practicing at the hospital to discriminate against such 
     beneficiaries;
       ``(iv) that is located in a State in which the average bed 
     capacity in the State is less than the national average bed 
     capacity; and
       ``(v) that has an average bed occupancy rate that is 
     greater than the average bed occupancy rate in the State in 
     which the hospital is located.
       ``(F) Procedure rooms.--In this subsection, the term 
     `procedure rooms' includes rooms in which catheterizations, 
     angiographies, angiograms, and endoscopies are performed, 
     except such term shall not include emergency rooms or 
     departments (exclusive of rooms in which catheterizations, 
     angiographies, angiograms, and endoscopies are performed).
       ``(G) Publication of final decisions.--Not later than 60 
     days after receiving a complete application under this 
     paragraph, the Secretary shall publish in the Federal 
     Register the final decision with respect to such application.
       ``(H) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the process under this paragraph 
     (including the establishment of such process).
       ``(4) Collection of ownership and investment information.--
     For purposes of subparagraphs (A)(i) and (D)(i) of paragraph 
     (1), the Secretary shall collect physician ownership and 
     investment information for each hospital.
       ``(5) Physician owner or investor defined.--For purposes of 
     this subsection, the term `physician owner or investor' means 
     a physician (or an immediate family member of such physician) 
     with a direct or an indirect ownership or investment interest 
     in the hospital.
       ``(6) Clarification.--Nothing in this subsection shall be 
     construed as preventing the Secretary from revoking a 
     hospital's provider agreement if not in compliance with 
     regulations implementing section 1866.''.
       (b) Enforcement.--
       (1) Ensuring compliance.--The Secretary of Health and Human 
     Services shall establish policies and procedures to ensure 
     compliance with the requirements described in subsection 
     (i)(1) of section 1877 of the Social Security Act, as added 
     by subsection (a)(3), beginning on the date such requirements 
     first apply. Such policies and procedures may include 
     unannounced site reviews of hospitals.
       (2) Audits.--Beginning not later than November 1, 2011, the 
     Secretary of Health and Human Services shall conduct audits 
     to determine if hospitals violate the requirements referred 
     to in paragraph (1).

     SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN 
                   OWNERSHIP OR INVESTMENT INTERESTS.

       Part A of title XI of the Social Security Act (42 U.S.C. 
     1301 et seq.) is amended by inserting after section 1128F the 
     following new section:

     ``SEC. 1128G. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN 
                   OWNERSHIP OR INVESTMENT INTERESTS.

       ``(a) Transparency Reports.--
       ``(1) Payments or other transfers of value.--
       ``(A) In general.--On March 31, 2013, and on the 90th day 
     of each calendar year beginning thereafter, any applicable 
     manufacturer that provides a payment or other transfer of 
     value to a covered recipient (or to an entity or individual 
     at the request of or designated on behalf of a covered 
     recipient), shall submit to the Secretary, in such electronic 
     form as the Secretary shall require, the following 
     information with respect to the preceding calendar year:
       ``(i) The name of the covered recipient.
       ``(ii) The business address of the covered recipient and, 
     in the case of a covered recipient who is a physician, the 
     specialty and National Provider Identifier of the covered 
     recipient.
       ``(iii) The amount of the payment or other transfer of 
     value.
       ``(iv) The dates on which the payment or other transfer of 
     value was provided to the covered recipient.
       ``(v) A description of the form of the payment or other 
     transfer of value, indicated (as appropriate for all that 
     apply) as--

       ``(I) cash or a cash equivalent;
       ``(II) in-kind items or services;
       ``(III) stock, a stock option, or any other ownership 
     interest, dividend, profit, or other return on investment; or
       ``(IV) any other form of payment or other transfer of value 
     (as defined by the Secretary).

       ``(vi) A description of the nature of the payment or other 
     transfer of value, indicated (as appropriate for all that 
     apply) as--

       ``(I) consulting fees;
       ``(II) compensation for services other than consulting;
       ``(III) honoraria;
       ``(IV) gift;
       ``(V) entertainment;
       ``(VI) food;
       ``(VII) travel (including the specified destinations);
       ``(VIII) education;
       ``(IX) research;
       ``(X) charitable contribution;
       ``(XI) royalty or license;
       ``(XII) current or prospective ownership or investment 
     interest;
       ``(XIII) direct compensation for serving as faculty or as a 
     speaker for a medical education program;
       ``(XIV) grant; or
       ``(XV) any other nature of the payment or other transfer of 
     value (as defined by the Secretary).

       ``(vii) If the payment or other transfer of value is 
     related to marketing, education, or research specific to a 
     covered drug, device, biological, or medical supply, the name 
     of that covered drug, device, biological, or medical supply.
       ``(viii) Any other categories of information regarding the 
     payment or other transfer of value the Secretary determines 
     appropriate.
       ``(B) Special rule for certain payments or other transfers 
     of value.--In the case where

[[Page 4356]]

     an applicable manufacturer provides a payment or other 
     transfer of value to an entity or individual at the request 
     of or designated on behalf of a covered recipient, the 
     applicable manufacturer shall disclose that payment or other 
     transfer of value under the name of the covered recipient.
       ``(2) Physician ownership.--In addition to the requirement 
     under paragraph (1)(A), on March 31, 2013, and on the 90th 
     day of each calendar year beginning thereafter, any 
     applicable manufacturer or applicable group purchasing 
     organization shall submit to the Secretary, in such 
     electronic form as the Secretary shall require, the following 
     information regarding any ownership or investment interest 
     (other than an ownership or investment interest in a publicly 
     traded security and mutual fund, as described in section 
     1877(c)) held by a physician (or an immediate family member 
     of such physician (as defined for purposes of section 
     1877(a))) in the applicable manufacturer or applicable group 
     purchasing organization during the preceding year:
       ``(A) The dollar amount invested by each physician holding 
     such an ownership or investment interest.
       ``(B) The value and terms of each such ownership or 
     investment interest.
       ``(C) Any payment or other transfer of value provided to a 
     physician holding such an ownership or investment interest 
     (or to an entity or individual at the request of or 
     designated on behalf of a physician holding such an ownership 
     or investment interest), including the information described 
     in clauses (i) through (viii) of paragraph (1)(A), except 
     that in applying such clauses, `physician' shall be 
     substituted for `covered recipient' each place it appears.
       ``(D) Any other information regarding the ownership or 
     investment interest the Secretary determines appropriate.
       ``(b) Penalties for Noncompliance.--
       ``(1) Failure to report.--
       ``(A) In general.--Subject to subparagraph (B) except as 
     provided in paragraph (2), any applicable manufacturer or 
     applicable group purchasing organization that fails to submit 
     information required under subsection (a) in a timely manner 
     in accordance with rules or regulations promulgated to carry 
     out such subsection, shall be subject to a civil money 
     penalty of not less than $1,000, but not more than $10,000, 
     for each payment or other transfer of value or ownership or 
     investment interest not reported as required under such 
     subsection. Such penalty shall be imposed and collected in 
     the same manner as civil money penalties under subsection (a) 
     of section 1128A are imposed and collected under that 
     section.
       ``(B) Limitation.--The total amount of civil money 
     penalties imposed under subparagraph (A) with respect to each 
     annual submission of information under subsection (a) by an 
     applicable manufacturer or applicable group purchasing 
     organization shall not exceed $150,000.
       ``(2) Knowing failure to report.--
       ``(A) In general.--Subject to subparagraph (B), any 
     applicable manufacturer or applicable group purchasing 
     organization that knowingly fails to submit information 
     required under subsection (a) in a timely manner in 
     accordance with rules or regulations promulgated to carry out 
     such subsection, shall be subject to a civil money penalty of 
     not less than $10,000, but not more than $100,000, for each 
     payment or other transfer of value or ownership or investment 
     interest not reported as required under such subsection. Such 
     penalty shall be imposed and collected in the same manner as 
     civil money penalties under subsection (a) of section 1128A 
     are imposed and collected under that section.
       ``(B) Limitation.--The total amount of civil money 
     penalties imposed under subparagraph (A) with respect to each 
     annual submission of information under subsection (a) by an 
     applicable manufacturer or applicable group purchasing 
     organization shall not exceed $1,000,000.
       ``(3) Use of funds.--Funds collected by the Secretary as a 
     result of the imposition of a civil money penalty under this 
     subsection shall be used to carry out this section.
       ``(c) Procedures for Submission of Information and Public 
     Availability.--
       ``(1) In general.--
       ``(A) Establishment.--Not later than October 1, 2011, the 
     Secretary shall establish procedures--
       ``(i) for applicable manufacturers and applicable group 
     purchasing organizations to submit information to the 
     Secretary under subsection (a); and
       ``(ii) for the Secretary to make such information submitted 
     available to the public.
       ``(B) Definition of terms.--The procedures established 
     under subparagraph (A) shall provide for the definition of 
     terms (other than those terms defined in subsection (e)), as 
     appropriate, for purposes of this section.
       ``(C) Public availability.--Except as provided in 
     subparagraph (E), the procedures established under 
     subparagraph (A)(ii) shall ensure that, not later than 
     September 30, 2013, and on June 30 of each calendar year 
     beginning thereafter, the information submitted under 
     subsection (a) with respect to the preceding calendar year is 
     made available through an Internet website that--
       ``(i) is searchable and is in a format that is clear and 
     understandable;
       ``(ii) contains information that is presented by the name 
     of the applicable manufacturer or applicable group purchasing 
     organization, the name of the covered recipient, the business 
     address of the covered recipient, the specialty of the 
     covered recipient, the value of the payment or other transfer 
     of value, the date on which the payment or other transfer of 
     value was provided to the covered recipient, the form of the 
     payment or other transfer of value, indicated (as 
     appropriate) under subsection (a)(1)(A)(v), the nature of the 
     payment or other transfer of value, indicated (as 
     appropriate) under subsection (a)(1)(A)(vi), and the name of 
     the covered drug, device, biological, or medical supply, as 
     applicable;
       ``(iii) contains information that is able to be easily 
     aggregated and downloaded;
       ``(iv) contains a description of any enforcement actions 
     taken to carry out this section, including any penalties 
     imposed under subsection (b), during the preceding year;
       ``(v) contains background information on industry-physician 
     relationships;
       ``(vi) in the case of information submitted with respect to 
     a payment or other transfer of value described in 
     subparagraph (E)(i), lists such information separately from 
     the other information submitted under subsection (a) and 
     designates such separately listed information as funding for 
     clinical research;
       ``(vii) contains any other information the Secretary 
     determines would be helpful to the average consumer;
       ``(viii) does not contain the National Provider Identifier 
     of the covered recipient, and
       ``(ix) subject to subparagraph (D), provides the applicable 
     manufacturer, applicable group purchasing organization, or 
     covered recipient an opportunity to review and submit 
     corrections to the information submitted with respect to the 
     applicable manufacturer, applicable group purchasing 
     organization, or covered recipient, respectively, for a 
     period of not less than 45 days prior to such information 
     being made available to the public.
       ``(D) Clarification of time period for review and 
     corrections.--In no case may the 45-day period for review and 
     submission of corrections to information under subparagraph 
     (C)(ix) prevent such information from being made available to 
     the public in accordance with the dates described in the 
     matter preceding clause (i) in subparagraph (C).
       ``(E) Delayed publication for payments made pursuant to 
     product research or development agreements and clinical 
     investigations.--
       ``(i) In general.--In the case of information submitted 
     under subsection (a) with respect to a payment or other 
     transfer of value made to a covered recipient by an 
     applicable manufacturer pursuant to a product research or 
     development agreement for services furnished in connection 
     with research on a potential new medical technology or a new 
     application of an existing medical technology or the 
     development of a new drug, device, biological, or medical 
     supply, or by an applicable manufacturer in connection with a 
     clinical investigation regarding a new drug, device, 
     biological, or medical supply, the procedures established 
     under subparagraph (A)(ii) shall provide that such 
     information is made available to the public on the first date 
     described in the matter preceding clause (i) in subparagraph 
     (C) after the earlier of the following:

       ``(I) The date of the approval or clearance of the covered 
     drug, device, biological, or medical supply by the Food and 
     Drug Administration.
       ``(II) Four calendar years after the date such payment or 
     other transfer of value was made.

       ``(ii) Confidentiality of information prior to 
     publication.--Information described in clause (i) shall be 
     considered confidential and shall not be subject to 
     disclosure under section 552 of title 5, United States Code, 
     or any other similar Federal, State, or local law, until on 
     or after the date on which the information is made available 
     to the public under such clause.
       ``(2) Consultation.--In establishing the procedures under 
     paragraph (1), the Secretary shall consult with the Inspector 
     General of the Department of Health and Human Services, 
     affected industry, consumers, consumer advocates, and other 
     interested parties in order to ensure that the information 
     made available to the public under such paragraph is 
     presented in the appropriate overall context.
       ``(d) Annual Reports and Relation to State Laws.--
       ``(1) Annual report to congress.--Not later than April 1 of 
     each year beginning with 2013, the Secretary shall submit to 
     Congress a report that includes the following:
       ``(A) The information submitted under subsection (a) during 
     the preceding year, aggregated for each applicable 
     manufacturer and applicable group purchasing organization 
     that submitted such information during such year (except, in 
     the case of information submitted with respect to a payment 
     or other transfer of value described in subsection 
     (c)(1)(E)(i), such information shall be included in the first 
     report submitted to Congress after the date on which such 
     information is made available to the public under such 
     subsection).
       ``(B) A description of any enforcement actions taken to 
     carry out this section, including any penalties imposed under 
     subsection (b), during the preceding year.
       ``(2) Annual reports to states.--Not later than September 
     30, 2013 and on June 30 of each calendar year thereafter, the 
     Secretary shall submit to States a report that includes a 
     summary of the information submitted under subsection (a) 
     during the preceding year with respect to covered recipients 
     in the State (except, in the case of information submitted 
     with respect to a payment or other transfer of value 
     described in subsection (c)(1)(E)(i), such information shall 
     be included in the first report submitted to States after the 
     date on which such information is made available to the 
     public under such subsection).

[[Page 4357]]

       ``(3) Relation to state laws.--
       ``(A) In general.--In the case of a payment or other 
     transfer of value provided by an applicable manufacturer that 
     is received by a covered recipient (as defined in subsection 
     (e)) on or after January 1, 2012, subject to subparagraph 
     (B), the provisions of this section shall preempt any statute 
     or regulation of a State or of a political subdivision of a 
     State that requires an applicable manufacturer (as so 
     defined) to disclose or report, in any format, the type of 
     information (as described in subsection (a)) regarding such 
     payment or other transfer of value.
       ``(B) No preemption of additional requirements.--
     Subparagraph (A) shall not preempt any statute or regulation 
     of a State or of a political subdivision of a State that 
     requires the disclosure or reporting of information--
       ``(i) not of the type required to be disclosed or reported 
     under this section;
       ``(ii) described in subsection (e)(10)(B), except in the 
     case of information described in clause (i) of such 
     subsection;
       ``(iii) by any person or entity other than an applicable 
     manufacturer (as so defined) or a covered recipient (as 
     defined in subsection (e)); or
       ``(iv) to a Federal, State, or local governmental agency 
     for public health surveillance, investigation, or other 
     public health purposes or health oversight purposes.
       ``(C) Nothing in subparagraph (A) shall be construed to 
     limit the discovery or admissibility of information described 
     in such subparagraph in a criminal, civil, or administrative 
     proceeding.
       ``(4) Consultation.--The Secretary shall consult with the 
     Inspector General of the Department of Health and Human 
     Services on the implementation of this section.
       ``(e) Definitions.--In this section:
       ``(1) Applicable group purchasing organization.--The term 
     `applicable group purchasing organization' means a group 
     purchasing organization (as defined by the Secretary) that 
     purchases, arranges for, or negotiates the purchase of a 
     covered drug, device, biological, or medical supply which is 
     operating in the United States, or in a territory, 
     possession, or commonwealth of the United States.
       ``(2) Applicable manufacturer.--The term `applicable 
     manufacturer' means a manufacturer of a covered drug, device, 
     biological, or medical supply which is operating in the 
     United States, or in a territory, possession, or commonwealth 
     of the United States.
       ``(3) Clinical investigation.--The term `clinical 
     investigation' means any experiment involving 1 or more human 
     subjects, or materials derived from human subjects, in which 
     a drug or device is administered, dispensed, or used.
       ``(4) Covered device.--The term `covered device' means any 
     device for which payment is available under title XVIII or a 
     State plan under title XIX or XXI (or a waiver of such a 
     plan).
       ``(5) Covered drug, device, biological, or medical 
     supply.--The term `covered drug, device, biological, or 
     medical supply' means any drug, biological product, device, 
     or medical supply for which payment is available under title 
     XVIII or a State plan under title XIX or XXI (or a waiver of 
     such a plan).
       ``(6) Covered recipient.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the term `covered recipient' means the following:
       ``(i) A physician.
       ``(ii) A teaching hospital.
       ``(B) Exclusion.--Such term does not include a physician 
     who is an employee of the applicable manufacturer that is 
     required to submit information under subsection (a).
       ``(7) Employee.--The term `employee' has the meaning given 
     such term in section 1877(h)(2).
       ``(8) Knowingly.--The term `knowingly' has the meaning 
     given such term in section 3729(b) of title 31, United States 
     Code.
       ``(9) Manufacturer of a covered drug, device, biological, 
     or medical supply.--The term `manufacturer of a covered drug, 
     device, biological, or medical supply' means any entity which 
     is engaged in the production, preparation, propagation, 
     compounding, or conversion of a covered drug, device, 
     biological, or medical supply (or any entity under common 
     ownership with such entity which provides assistance or 
     support to such entity with respect to the production, 
     preparation, propagation, compounding, conversion, marketing, 
     promotion, sale, or distribution of a covered drug, device, 
     biological, or medical supply).
       ``(10) Payment or other transfer of value.--
       ``(A) In general.--The term `payment or other transfer of 
     value' means a transfer of anything of value. Such term does 
     not include a transfer of anything of value that is made 
     indirectly to a covered recipient through a third party in 
     connection with an activity or service in the case where the 
     applicable manufacturer is unaware of the identity of the 
     covered recipient.
       ``(B) Exclusions.--An applicable manufacturer shall not be 
     required to submit information under subsection (a) with 
     respect to the following:
       ``(i) A transfer of anything the value of which is less 
     than $10, unless the aggregate amount transferred to, 
     requested by, or designated on behalf of the covered 
     recipient by the applicable manufacturer during the calendar 
     year exceeds $100. For calendar years after 2012, the dollar 
     amounts specified in the preceding sentence shall be 
     increased by the same percentage as the percentage increase 
     in the consumer price index for all urban consumers (all 
     items; U.S. city average) for the 12-month period ending with 
     June of the previous year.
       ``(ii) Product samples that are not intended to be sold and 
     are intended for patient use.
       ``(iii) Educational materials that directly benefit 
     patients or are intended for patient use.
       ``(iv) The loan of a covered device for a short-term trial 
     period, not to exceed 90 days, to permit evaluation of the 
     covered device by the covered recipient.
       ``(v) Items or services provided under a contractual 
     warranty, including the replacement of a covered device, 
     where the terms of the warranty are set forth in the purchase 
     or lease agreement for the covered device.
       ``(vi) A transfer of anything of value to a covered 
     recipient when the covered recipient is a patient and not 
     acting in the professional capacity of a covered recipient.
       ``(vii) Discounts (including rebates).
       ``(viii) In-kind items used for the provision of charity 
     care.
       ``(ix) A dividend or other profit distribution from, or 
     ownership or investment interest in, a publicly traded 
     security and mutual fund (as described in section 1877(c)).
       ``(x) In the case of an applicable manufacturer who offers 
     a self-insured plan, payments for the provision of health 
     care to employees under the plan.
       ``(xi) In the case of a covered recipient who is a licensed 
     non-medical professional, a transfer of anything of value to 
     the covered recipient if the transfer is payment solely for 
     the non-medical professional services of such licensed non-
     medical professional.
       ``(xii) In the case of a covered recipient who is a 
     physician, a transfer of anything of value to the covered 
     recipient if the transfer is payment solely for the services 
     of the covered recipient with respect to a civil or criminal 
     action or an administrative proceeding.
       ``(11) Physician.--The term `physician' has the meaning 
     given that term in section 1861(r).''.

     SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY 
                   SERVICES EXCEPTION TO THE PROHIBITION ON 
                   PHYSICIAN SELF-REFERRAL FOR CERTAIN IMAGING 
                   SERVICES.

       (a) In General.--Section 1877(b)(2) of the Social Security 
     Act (42 U.S.C. 1395nn(b)(2)) is amended by adding at the end 
     the following new sentence: ``Such requirements shall, with 
     respect to magnetic resonance imaging, computed tomography, 
     positron emission tomography, and any other designated health 
     services specified under subsection (h)(6)(D) that the 
     Secretary determines appropriate, include a requirement that 
     the referring physician inform the individual in writing at 
     the time of the referral that the individual may obtain the 
     services for which the individual is being referred from a 
     person other than a person described in subparagraph (A)(i) 
     and provide such individual with a written list of suppliers 
     (as defined in section 1861(d)) who furnish such services in 
     the area in which such individual resides.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to services furnished on or after January 1, 
     2010.

     SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY.

       Part A of title XI of the Social Security Act (42 U.S.C. 
     1301 et seq.), as amended by section 6002, is amended by 
     inserting after section 1128G the following new section:

     ``SEC. 1128H. REPORTING OF INFORMATION RELATING TO DRUG 
                   SAMPLES.

       ``(a) In General.--Not later than April 1 of each year 
     (beginning with 2012), each manufacturer and authorized 
     distributor of record of an applicable drug shall submit to 
     the Secretary (in a form and manner specified by the 
     Secretary) the following information with respect to the 
     preceding year:
       ``(1) In the case of a manufacturer or authorized 
     distributor of record which makes distributions by mail or 
     common carrier under subsection (d)(2) of section 503 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 353), the 
     identity and quantity of drug samples requested and the 
     identity and quantity of drug samples distributed under such 
     subsection during that year, aggregated by--
       ``(A) the name, address, professional designation, and 
     signature of the practitioner making the request under 
     subparagraph (A)(i) of such subsection, or of any individual 
     who makes or signs for the request on behalf of the 
     practitioner; and
       ``(B) any other category of information determined 
     appropriate by the Secretary.
       ``(2) In the case of a manufacturer or authorized 
     distributor of record which makes distributions by means 
     other than mail or common carrier under subsection (d)(3) of 
     such section 503, the identity and quantity of drug samples 
     requested and the identity and quantity of drug samples 
     distributed under such subsection during that year, 
     aggregated by--
       ``(A) the name, address, professional designation, and 
     signature of the practitioner making the request under 
     subparagraph (A)(i) of such subsection, or of any individual 
     who makes or signs for the request on behalf of the 
     practitioner; and
       ``(B) any other category of information determined 
     appropriate by the Secretary.
       ``(b) Definitions.--In this section:
       ``(1) Applicable drug.--The term `applicable drug' means a 
     drug--
       ``(A) which is subject to subsection (b) of such section 
     503; and
       ``(B) for which payment is available under title XVIII or a 
     State plan under title XIX or XXI (or a waiver of such a 
     plan).
       ``(2) Authorized distributor of record.--The term 
     `authorized distributor of record' has the meaning given that 
     term in subsection (e)(3)(A) of such section.

[[Page 4358]]

       ``(3) Manufacturer.--The term `manufacturer' has the 
     meaning given that term for purposes of subsection (d) of 
     such section.''.

     SEC. 6005. PHARMACY BENEFIT MANAGERS TRANSPARENCY 
                   REQUIREMENTS.

       Part A of title XI of the Social Security Act (42 U.S.C. 
     1301 et seq.) is amended by inserting after section 1150 the 
     following new section:

     ``SEC. 1150A. PHARMACY BENEFIT MANAGERS TRANSPARENCY 
                   REQUIREMENTS.

       ``(a) Provision of Information.--A health benefits plan or 
     any entity that provides pharmacy benefits management 
     services on behalf of a health benefits plan (in this section 
     referred to as a `PBM') that manages prescription drug 
     coverage under a contract with--
       ``(1) a PDP sponsor of a prescription drug plan or an MA 
     organization offering an MA-PD plan under part D of title 
     XVIII; or
       ``(2) a qualified health benefits plan offered through an 
     exchange established by a State under section 1311 of the 
     Patient Protection and Affordable Care Act,
     shall provide the information described in subsection (b) to 
     the Secretary and, in the case of a PBM, to the plan with 
     which the PBM is under contract with, at such times, and in 
     such form and manner, as the Secretary shall specify.
       ``(b) Information Described.--The information described in 
     this subsection is the following with respect to services 
     provided by a health benefits plan or PBM for a contract 
     year:
       ``(1) The percentage of all prescriptions that were 
     provided through retail pharmacies compared to mail order 
     pharmacies, and the percentage of prescriptions for which a 
     generic drug was available and dispensed (generic dispensing 
     rate), by pharmacy type (which includes an independent 
     pharmacy, chain pharmacy, supermarket pharmacy, or mass 
     merchandiser pharmacy that is licensed as a pharmacy by the 
     State and that dispenses medication to the general public), 
     that is paid by the health benefits plan or PBM under the 
     contract.
       ``(2) The aggregate amount, and the type of rebates, 
     discounts, or price concessions (excluding bona fide service 
     fees, which include but are not limited to distribution 
     service fees, inventory management fees, product stocking 
     allowances, and fees associated with administrative services 
     agreements and patient care programs (such as medication 
     compliance programs and patient education programs)) that the 
     PBM negotiates that are attributable to patient utilization 
     under the plan, and the aggregate amount of the rebates, 
     discounts, or price concessions that are passed through to 
     the plan sponsor, and the total number of prescriptions that 
     were dispensed.
       ``(3) The aggregate amount of the difference between the 
     amount the health benefits plan pays the PBM and the amount 
     that the PBM pays retail pharmacies, and mail order 
     pharmacies, and the total number of prescriptions that were 
     dispensed.
       ``(c) Confidentiality.--Information disclosed by a health 
     benefits plan or PBM under this section is confidential and 
     shall not be disclosed by the Secretary or by a plan 
     receiving the information, except that the Secretary may 
     disclose the information in a form which does not disclose 
     the identity of a specific PBM, plan, or prices charged for 
     drugs, for the following purposes:
       ``(1) As the Secretary determines to be necessary to carry 
     out this section or part D of title XVIII.
       ``(2) To permit the Comptroller General to review the 
     information provided.
       ``(3) To permit the Director of the Congressional Budget 
     Office to review the information provided.
       ``(4) To States to carry out section 1311 of the Patient 
     Protection and Affordable Care Act.
       ``(d) Penalties.--The provisions of subsection (b)(3)(C) of 
     section 1927 shall apply to a health benefits plan or PBM 
     that fails to provide information required under subsection 
     (a) on a timely basis or that knowingly provides false 
     information in the same manner as such provisions apply to a 
     manufacturer with an agreement under that section.''.

         Subtitle B--Nursing Home Transparency and Improvement

             PART I--IMPROVING TRANSPARENCY OF INFORMATION

     SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL 
                   DISCLOSABLE PARTIES INFORMATION.

       (a) In General.--Section 1124 of the Social Security Act 
     (42 U.S.C. 1320a-3) is amended by adding at the end the 
     following new subsection:
       ``(c) Required Disclosure of Ownership and Additional 
     Disclosable Parties Information.--
       ``(1) Disclosure.--A facility shall have the information 
     described in paragraph (2) available--
       ``(A) during the period beginning on the date of the 
     enactment of this subsection and ending on the date such 
     information is made available to the public under section 
     6101(b) of the Patient Protection and Affordable Care Act for 
     submission to the Secretary, the Inspector General of the 
     Department of Health and Human Services, the State in which 
     the facility is located, and the State long-term care 
     ombudsman in the case where the Secretary, the Inspector 
     General, the State, or the State long-term care ombudsman 
     requests such information; and
       ``(B) beginning on the effective date of the final 
     regulations promulgated under paragraph (3)(A), for reporting 
     such information in accordance with such final regulations.

     Nothing in subparagraph (A) shall be construed as authorizing 
     a facility to dispose of or delete information described in 
     such subparagraph after the effective date of the final 
     regulations promulgated under paragraph (3)(A).
       ``(2) Information described.--
       ``(A) In general.--The following information is described 
     in this paragraph:
       ``(i) The information described in subsections (a) and (b), 
     subject to subparagraph (C).
       ``(ii) The identity of and information on--

       ``(I) each member of the governing body of the facility, 
     including the name, title, and period of service of each such 
     member;
       ``(II) each person or entity who is an officer, director, 
     member, partner, trustee, or managing employee of the 
     facility, including the name, title, and period of service of 
     each such person or entity; and
       ``(III) each person or entity who is an additional 
     disclosable party of the facility.

       ``(iii) The organizational structure of each additional 
     disclosable party of the facility and a description of the 
     relationship of each such additional disclosable party to the 
     facility and to one another.
       ``(B) Special rule where information is already reported or 
     submitted.--To the extent that information reported by a 
     facility to the Internal Revenue Service on Form 990, 
     information submitted by a facility to the Securities and 
     Exchange Commission, or information otherwise submitted to 
     the Secretary or any other Federal agency contains the 
     information described in clauses (i), (ii), or (iii) of 
     subparagraph (A), the facility may provide such Form or such 
     information submitted to meet the requirements of paragraph 
     (1).
       ``(C) Special rule.--In applying subparagraph (A)(i)--
       ``(i) with respect to subsections (a) and (b), `ownership 
     or control interest' shall include direct or indirect 
     interests, including such interests in intermediate entities; 
     and
       ``(ii) subsection (a)(3)(A)(ii) shall include the owner of 
     a whole or part interest in any mortgage, deed of trust, 
     note, or other obligation secured, in whole or in part, by 
     the entity or any of the property or assets thereof, if the 
     interest is equal to or exceeds 5 percent of the total 
     property or assets of the entirety.
       ``(3) Reporting.--
       ``(A) In general.--Not later than the date that is 2 years 
     after the date of the enactment of this subsection, the 
     Secretary shall promulgate final regulations requiring, 
     effective on the date that is 90 days after the date on which 
     such final regulations are published in the Federal Register, 
     a facility to report the information described in paragraph 
     (2) to the Secretary in a standardized format, and such other 
     regulations as are necessary to carry out this subsection. 
     Such final regulations shall ensure that the facility 
     certifies, as a condition of participation and payment under 
     the program under title XVIII or XIX, that the information 
     reported by the facility in accordance with such final 
     regulations is, to the best of the facility's knowledge, 
     accurate and current.
       ``(B) Guidance.--The Secretary shall provide guidance and 
     technical assistance to States on how to adopt the 
     standardized format under subparagraph (A).
       ``(4) No effect on existing reporting requirements.--
     Nothing in this subsection shall reduce, diminish, or alter 
     any reporting requirement for a facility that is in effect as 
     of the date of the enactment of this subsection.
       ``(5) Definitions.--In this subsection:
       ``(A) Additional disclosable party.--The term `additional 
     disclosable party' means, with respect to a facility, any 
     person or entity who--
       ``(i) exercises operational, financial, or managerial 
     control over the facility or a part thereof, or provides 
     policies or procedures for any of the operations of the 
     facility, or provides financial or cash management services 
     to the facility;
       ``(ii) leases or subleases real property to the facility, 
     or owns a whole or part interest equal to or exceeding 5 
     percent of the total value of such real property; or
       ``(iii) provides management or administrative services, 
     management or clinical consulting services, or accounting or 
     financial services to the facility.
       ``(B) Facility.--The term `facility' means a disclosing 
     entity which is--
       ``(i) a skilled nursing facility (as defined in section 
     1819(a)); or
       ``(ii) a nursing facility (as defined in section 1919(a)).
       ``(C) Managing employee.--The term `managing employee' 
     means, with respect to a facility, an individual (including a 
     general manager, business manager, administrator, director, 
     or consultant) who directly or indirectly manages, advises, 
     or supervises any element of the practices, finances, or 
     operations of the facility.
       ``(D) Organizational structure.--The term `organizational 
     structure' means, in the case of--
       ``(i) a corporation, the officers, directors, and 
     shareholders of the corporation who have an ownership 
     interest in the corporation which is equal to or exceeds 5 
     percent;
       ``(ii) a limited liability company, the members and 
     managers of the limited liability company (including, as 
     applicable, what percentage each member and manager has of 
     the ownership interest in the limited liability company);
       ``(iii) a general partnership, the partners of the general 
     partnership;
       ``(iv) a limited partnership, the general partners and any 
     limited partners of the limited partnership who have an 
     ownership interest in the limited partnership which is equal 
     to or exceeds 10 percent;
       ``(v) a trust, the trustees of the trust;

[[Page 4359]]

       ``(vi) an individual, contact information for the 
     individual; and
       ``(vii) any other person or entity, such information as the 
     Secretary determines appropriate.''.
       (b) Public Availability of Information.--Not later than the 
     date that is 1 year after the date on which the final 
     regulations promulgated under section 1124(c)(3)(A) of the 
     Social Security Act, as added by subsection (a), are 
     published in the Federal Register, the Secretary of Health 
     and Human Services shall make the information reported in 
     accordance with such final regulations available to the 
     public in accordance with procedures established by the 
     Secretary.
       (c) Conforming Amendments.--
       (1) In general.--
       (A) Skilled nursing facilities.--Section 1819(d)(1) of the 
     Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by 
     striking subparagraph (B) and redesignating subparagraph (C) 
     as subparagraph (B).
       (B) Nursing facilities.--Section 1919(d)(1) of the Social 
     Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking 
     subparagraph (B) and redesignating subparagraph (C) as 
     subparagraph (B).
       (2) Effective date.--The amendments made by paragraph (1) 
     shall take effect on the date on which the Secretary makes 
     the information described in subsection (b)(1) available to 
     the public under such subsection.

     SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING 
                   FACILITIES AND NURSING FACILITIES.

       Part A of title XI of the Social Security Act (42 U.S.C. 
     1301 et seq.), as amended by sections 6002 and 6004, is 
     amended by inserting after section 1128H the following new 
     section:

     ``SEC. 1128I. ACCOUNTABILITY REQUIREMENTS FOR FACILITIES.

       ``(a) Definition of Facility.--In this section, the term 
     `facility' means--
       ``(1) a skilled nursing facility (as defined in section 
     1819(a)); or
       ``(2) a nursing facility (as defined in section 1919(a)).
       ``(b) Effective Compliance and Ethics Programs.--
       ``(1) Requirement.--On or after the date that is 36 months 
     after the date of the enactment of this section, a facility 
     shall, with respect to the entity that operates the facility 
     (in this subparagraph referred to as the `operating 
     organization' or `organization'), have in operation a 
     compliance and ethics program that is effective in preventing 
     and detecting criminal, civil, and administrative violations 
     under this Act and in promoting quality of care consistent 
     with regulations developed under paragraph (2).
       ``(2) Development of regulations.--
       ``(A) In general.--Not later than the date that is 2 years 
     after such date of the enactment, the Secretary, working 
     jointly with the Inspector General of the Department of 
     Health and Human Services, shall promulgate regulations for 
     an effective compliance and ethics program for operating 
     organizations, which may include a model compliance program.
       ``(B)  Design of regulations.--Such regulations with 
     respect to specific elements or formality of a program shall, 
     in the case of an organization that operates 5 or more 
     facilities, vary with the size of the organization, such that 
     larger organizations should have a more formal program and 
     include established written policies defining the standards 
     and procedures to be followed by its employees. Such 
     requirements may specifically apply to the corporate level 
     management of multi unit nursing home chains.
       ``(C) Evaluation.--Not later than 3 years after the date of 
     the promulgation of regulations under this paragraph, the 
     Secretary shall complete an evaluation of the compliance and 
     ethics programs required to be established under this 
     subsection. Such evaluation shall determine if such programs 
     led to changes in deficiency citations, changes in quality 
     performance, or changes in other metrics of patient quality 
     of care. The Secretary shall submit to Congress a report on 
     such evaluation and shall include in such report such 
     recommendations regarding changes in the requirements for 
     such programs as the Secretary determines appropriate.
       ``(3) Requirements for compliance and ethics programs.--In 
     this subsection, the term `compliance and ethics program' 
     means, with respect to a facility, a program of the operating 
     organization that--
       ``(A) has been reasonably designed, implemented, and 
     enforced so that it generally will be effective in preventing 
     and detecting criminal, civil, and administrative violations 
     under this Act and in promoting quality of care; and
       ``(B) includes at least the required components specified 
     in paragraph (4).
       ``(4) Required components of program.--The required 
     components of a compliance and ethics program of an operating 
     organization are the following:
       ``(A) The organization must have established compliance 
     standards and procedures to be followed by its employees and 
     other agents that are reasonably capable of reducing the 
     prospect of criminal, civil, and administrative violations 
     under this Act.
       ``(B) Specific individuals within high-level personnel of 
     the organization must have been assigned overall 
     responsibility to oversee compliance with such standards and 
     procedures and have sufficient resources and authority to 
     assure such compliance.
       ``(C) The organization must have used due care not to 
     delegate substantial discretionary authority to individuals 
     whom the organization knew, or should have known through the 
     exercise of due diligence, had a propensity to engage in 
     criminal, civil, and administrative violations under this 
     Act.
       ``(D) The organization must have taken steps to communicate 
     effectively its standards and procedures to all employees and 
     other agents, such as by requiring participation in training 
     programs or by disseminating publications that explain in a 
     practical manner what is required.
       ``(E) The organization must have taken reasonable steps to 
     achieve compliance with its standards, such as by utilizing 
     monitoring and auditing systems reasonably designed to detect 
     criminal, civil, and administrative violations under this Act 
     by its employees and other agents and by having in place and 
     publicizing a reporting system whereby employees and other 
     agents could report violations by others within the 
     organization without fear of retribution.
       ``(F) The standards must have been consistently enforced 
     through appropriate disciplinary mechanisms, including, as 
     appropriate, discipline of individuals responsible for the 
     failure to detect an offense.
       ``(G) After an offense has been detected, the organization 
     must have taken all reasonable steps to respond appropriately 
     to the offense and to prevent further similar offenses, 
     including any necessary modification to its program to 
     prevent and detect criminal, civil, and administrative 
     violations under this Act.
       ``(H) The organization must periodically undertake 
     reassessment of its compliance program to identify changes 
     necessary to reflect changes within the organization and its 
     facilities.
       ``(c) Quality Assurance and Performance Improvement 
     Program.--
       ``(1) In general.--Not later than December 31, 2011, the 
     Secretary shall establish and implement a quality assurance 
     and performance improvement program (in this subparagraph 
     referred to as the `QAPI program') for facilities, including 
     multi unit chains of facilities. Under the QAPI program, the 
     Secretary shall establish standards relating to quality 
     assurance and performance improvement with respect to 
     facilities and provide technical assistance to facilities on 
     the development of best practices in order to meet such 
     standards. Not later than 1 year after the date on which the 
     regulations are promulgated under paragraph (2), a facility 
     must submit to the Secretary a plan for the facility to meet 
     such standards and implement such best practices, including 
     how to coordinate the implementation of such plan with 
     quality assessment and assurance activities conducted under 
     sections 1819(b)(1)(B) and 1919(b)(1)(B), as applicable.
       ``(2) Regulations.--The Secretary shall promulgate 
     regulations to carry out this subsection.''.

     SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819 of the Social Security Act 
     (42 U.S.C. 1395i-3) is amended--
       (A) by redesignating subsection (i) as subsection (j); and
       (B) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Nursing Home Compare Website.--
       ``(1) Inclusion of additional information.--
       ``(A) In general.--The Secretary shall ensure that the 
     Department of Health and Human Services includes, as part of 
     the information provided for comparison of nursing homes on 
     the official Internet website of the Federal Government for 
     Medicare beneficiaries (commonly referred to as the `Nursing 
     Home Compare' Medicare website) (or a successor website), the 
     following information in a manner that is prominent, updated 
     on a timely basis, easily accessible, readily understandable 
     to consumers of long-term care services, and searchable:
       ``(i) Staffing data for each facility (including resident 
     census data and data on the hours of care provided per 
     resident per day) based on data submitted under section 
     1128I(g), including information on staffing turnover and 
     tenure, in a format that is clearly understandable to 
     consumers of long-term care services and allows such 
     consumers to compare differences in staffing between 
     facilities and State and national averages for the 
     facilities. Such format shall include--

       ``(I) concise explanations of how to interpret the data 
     (such as a plain English explanation of data reflecting 
     `nursing home staff hours per resident day');
       ``(II) differences in types of staff (such as training 
     associated with different categories of staff);
       ``(III) the relationship between nurse staffing levels and 
     quality of care; and
       ``(IV) an explanation that appropriate staffing levels vary 
     based on patient case mix.

       ``(ii) Links to State Internet websites with information 
     regarding State survey and certification programs, links to 
     Form 2567 State inspection reports (or a successor form) on 
     such websites, information to guide consumers in how to 
     interpret and understand such reports, and the facility plan 
     of correction or other response to such report. Any such 
     links shall be posted on a timely basis.
       ``(iii) The standardized complaint form developed under 
     section 1128I(f), including explanatory material on what 
     complaint forms are, how they are used, and how to file a 
     complaint with the State survey and certification program and 
     the State long-term care ombudsman program.
       ``(iv) Summary information on the number, type, severity, 
     and outcome of substantiated complaints.
       ``(v) The number of adjudicated instances of criminal 
     violations by a facility or the employees of a facility--

[[Page 4360]]

       ``(I) that were committed inside the facility;
       ``(II) with respect to such instances of violations or 
     crimes committed inside of the facility that were the 
     violations or crimes of abuse, neglect, and exploitation, 
     criminal sexual abuse, or other violations or crimes that 
     resulted in serious bodily injury; and
       ``(III) the number of civil monetary penalties levied 
     against the facility, employees, contractors, and other 
     agents.

       ``(B) Deadline for provision of information.--
       ``(i) In general.--Except as provided in clause (ii), the 
     Secretary shall ensure that the information described in 
     subparagraph (A) is included on such website (or a successor 
     website) not later than 1 year after the date of the 
     enactment of this subsection.
       ``(ii) Exception.--The Secretary shall ensure that the 
     information described in subparagraph (A)(i) is included on 
     such website (or a successor website) not later than the date 
     on which the requirements under section 1128I(g) are 
     implemented.
       ``(2) Review and modification of website.--
       ``(A) In general.--The Secretary shall establish a 
     process--
       ``(i) to review the accuracy, clarity of presentation, 
     timeliness, and comprehensiveness of information reported on 
     such website as of the day before the date of the enactment 
     of this subsection; and
       ``(ii) not later than 1 year after the date of the 
     enactment of this subsection, to modify or revamp such 
     website in accordance with the review conducted under clause 
     (i).
       ``(B) Consultation.--In conducting the review under 
     subparagraph (A)(i), the Secretary shall consult with--
       ``(i) State long-term care ombudsman programs;
       ``(ii) consumer advocacy groups;
       ``(iii) provider stakeholder groups; and
       ``(iv) any other representatives of programs or groups the 
     Secretary determines appropriate.''.
       (2) Timeliness of submission of survey and certification 
     information.--
       (A) In general.--Section 1819(g)(5) of the Social Security 
     Act (42 U.S.C. 1395i-3(g)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(E) Submission of survey and certification information to 
     the secretary.--In order to improve the timeliness of 
     information made available to the public under subparagraph 
     (A) and provided on the Nursing Home Compare Medicare website 
     under subsection (i), each State shall submit information 
     respecting any survey or certification made respecting a 
     skilled nursing facility (including any enforcement actions 
     taken by the State) to the Secretary not later than the date 
     on which the State sends such information to the facility. 
     The Secretary shall use the information submitted under the 
     preceding sentence to update the information provided on the 
     Nursing Home Compare Medicare website as expeditiously as 
     practicable but not less frequently than quarterly.''.
       (B) Effective date.--The amendment made by this paragraph 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (3) Special focus facility program.--Section 1819(f) of the 
     Social Security Act (42 U.S.C. 1395i-3(f)) is amended by 
     adding at the end the following new paragraph:
       ``(8) Special focus facility program.--
       ``(A) In general.--The Secretary shall conduct a special 
     focus facility program for enforcement of requirements for 
     skilled nursing facilities that the Secretary has identified 
     as having substantially failed to meet applicable requirement 
     of this Act.
       ``(B) Periodic surveys.--Under such program the Secretary 
     shall conduct surveys of each facility in the program not 
     less than once every 6 months.''.
       (b) Nursing Facilities.--
       (1) In general.--Section 1919 of the Social Security Act 
     (42 U.S.C. 1396r) is amended--
       (A) by redesignating subsection (i) as subsection (j); and
       (B) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Nursing Home Compare Website.--
       ``(1) Inclusion of additional information.--
       ``(A) In general.--The Secretary shall ensure that the 
     Department of Health and Human Services includes, as part of 
     the information provided for comparison of nursing homes on 
     the official Internet website of the Federal Government for 
     Medicare beneficiaries (commonly referred to as the `Nursing 
     Home Compare' Medicare website) (or a successor website), the 
     following information in a manner that is prominent, updated 
     on a timely basis, easily accessible, readily understandable 
     to consumers of long-term care services, and searchable:
       ``(i) Staffing data for each facility (including resident 
     census data and data on the hours of care provided per 
     resident per day) based on data submitted under section 
     1128I(g), including information on staffing turnover and 
     tenure, in a format that is clearly understandable to 
     consumers of long-term care services and allows such 
     consumers to compare differences in staffing between 
     facilities and State and national averages for the 
     facilities. Such format shall include--

       ``(I) concise explanations of how to interpret the data 
     (such as plain English explanation of data reflecting 
     `nursing home staff hours per resident day');
       ``(II) differences in types of staff (such as training 
     associated with different categories of staff);
       ``(III) the relationship between nurse staffing levels and 
     quality of care; and
       ``(IV) an explanation that appropriate staffing levels vary 
     based on patient case mix.

       ``(ii) Links to State Internet websites with information 
     regarding State survey and certification programs, links to 
     Form 2567 State inspection reports (or a successor form) on 
     such websites, information to guide consumers in how to 
     interpret and understand such reports, and the facility plan 
     of correction or other response to such report. Any such 
     links shall be posted on a timely basis.
       ``(iii) The standardized complaint form developed under 
     section 1128I(f), including explanatory material on what 
     complaint forms are, how they are used, and how to file a 
     complaint with the State survey and certification program and 
     the State long-term care ombudsman program.
       ``(iv) Summary information on the number, type, severity, 
     and outcome of substantiated complaints.
       ``(v) The number of adjudicated instances of criminal 
     violations by a facility or the employees of a facility--

       ``(I) that were committed inside of the facility; and
       ``(II) with respect to such instances of violations or 
     crimes committed outside of the facility, that were 
     violations or crimes that resulted in the serious bodily 
     injury of an elder.

       ``(B) Deadline for provision of information.--
       ``(i) In general.--Except as provided in clause (ii), the 
     Secretary shall ensure that the information described in 
     subparagraph (A) is included on such website (or a successor 
     website) not later than 1 year after the date of the 
     enactment of this subsection.
       ``(ii) Exception.--The Secretary shall ensure that the 
     information described in subparagraph (A)(i) is included on 
     such website (or a successor website) not later than the date 
     on which the requirements under section 1128I(g) are 
     implemented.
       ``(2) Review and modification of website.--
       ``(A) In general.--The Secretary shall establish a 
     process--
       ``(i) to review the accuracy, clarity of presentation, 
     timeliness, and comprehensiveness of information reported on 
     such website as of the day before the date of the enactment 
     of this subsection; and
       ``(ii) not later than 1 year after the date of the 
     enactment of this subsection, to modify or revamp such 
     website in accordance with the review conducted under clause 
     (i).
       ``(B) Consultation.--In conducting the review under 
     subparagraph (A)(i), the Secretary shall consult with--
       ``(i) State long-term care ombudsman programs;
       ``(ii) consumer advocacy groups;
       ``(iii) provider stakeholder groups;
       ``(iv) skilled nursing facility employees and their 
     representatives; and
       ``(v) any other representatives of programs or groups the 
     Secretary determines appropriate.''.
       (2) Timeliness of submission of survey and certification 
     information.--
       (A) In general.--Section 1919(g)(5) of the Social Security 
     Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(E) Submission of survey and certification information to 
     the secretary.--In order to improve the timeliness of 
     information made available to the public under subparagraph 
     (A) and provided on the Nursing Home Compare Medicare website 
     under subsection (i), each State shall submit information 
     respecting any survey or certification made respecting a 
     nursing facility (including any enforcement actions taken by 
     the State) to the Secretary not later than the date on which 
     the State sends such information to the facility. The 
     Secretary shall use the information submitted under the 
     preceding sentence to update the information provided on the 
     Nursing Home Compare Medicare website as expeditiously as 
     practicable but not less frequently than quarterly.''.
       (B) Effective date.--The amendment made by this paragraph 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (3) Special focus facility program.--Section 1919(f) of the 
     Social Security Act (42 U.S.C. 1396r(f)) is amended by adding 
     at the end of the following new paragraph:
       ``(10) Special focus facility program.--
       ``(A) In general.--The Secretary shall conduct a special 
     focus facility program for enforcement of requirements for 
     nursing facilities that the Secretary has identified as 
     having substantially failed to meet applicable requirements 
     of this Act.
       ``(B) Periodic surveys.--Under such program the Secretary 
     shall conduct surveys of each facility in the program not 
     less often than once every 6 months.''.
       (c) Availability of Reports on Surveys, Certifications, and 
     Complaint Investigations.--
       (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
     Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
     section 6101, is amended by adding at the end the following 
     new subparagraph:
       ``(C) Availability of survey, certification, and complaint 
     investigation reports.--A skilled nursing facility must--
       ``(i) have reports with respect to any surveys, 
     certifications, and complaint investigations made respecting 
     the facility during the 3 preceding years available for any 
     individual to review upon request; and
       ``(ii) post notice of the availability of such reports in 
     areas of the facility that are prominent and accessible to 
     the public.

[[Page 4361]]

     The facility shall not make available under clause (i) 
     identifying information about complainants or residents.''.

       (2) Nursing facilities.--Section 1919(d)(1) of the Social 
     Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 
     6101, is amended by adding at the end the following new 
     subparagraph:
       ``(V) Availability of survey, certification, and complaint 
     investigation reports.--A nursing facility must--
       ``(i) have reports with respect to any surveys, 
     certifications, and complaint investigations made respecting 
     the facility during the 3 preceding years available for any 
     individual to review upon request; and
       ``(ii) post notice of the availability of such reports in 
     areas of the facility that are prominent and accessible to 
     the public.

     The facility shall not make available under clause (i) 
     identifying information about complainants or residents.''.
       (3) Effective date.--The amendments made by this subsection 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (d) Guidance to States on Form 2567 State Inspection 
     Reports and Complaint Investigation Reports.--
       (1) Guidance.--The Secretary of Health and Human Services 
     (in this subtitle referred to as the ``Secretary'') shall 
     provide guidance to States on how States can establish 
     electronic links to Form 2567 State inspection reports (or a 
     successor form), complaint investigation reports, and a 
     facility's plan of correction or other response to such Form 
     2567 State inspection reports (or a successor form) on the 
     Internet website of the State that provides information on 
     skilled nursing facilities and nursing facilities and the 
     Secretary shall, if possible, include such information on 
     Nursing Home Compare.
       (2) Requirement.--Section 1902(a)(9) of the Social Security 
     Act (42 U.S.C. 1396a(a)(9)) is amended--
       (A) by striking ``and'' at the end of subparagraph (B);
       (B) by striking the semicolon at the end of subparagraph 
     (C) and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(D) that the State maintain a consumer-oriented website 
     providing useful information to consumers regarding all 
     skilled nursing facilities and all nursing facilities in the 
     State, including for each facility, Form 2567 State 
     inspection reports (or a successor form), complaint 
     investigation reports, the facility's plan of correction, and 
     such other information that the State or the Secretary 
     considers useful in assisting the public to assess the 
     quality of long term care options and the quality of care 
     provided by individual facilities;''.
       (3) Definitions.--In this subsection:
       (A) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (B) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (C) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395i-3(a)).
       (e) Development of Consumer Rights Information Page on 
     Nursing Home Compare Website.--Not later than 1 year after 
     the date of enactment of this Act, the Secretary shall ensure 
     that the Department of Health and Human Services, as part of 
     the information provided for comparison of nursing facilities 
     on the Nursing Home Compare Medicare website develops and 
     includes a consumer rights information page that contains 
     links to descriptions of, and information with respect to, 
     the following:
       (1) The documentation on nursing facilities that is 
     available to the public.
       (2) General information and tips on choosing a nursing 
     facility that meets the needs of the individual.
       (3) General information on consumer rights with respect to 
     nursing facilities.
       (4) The nursing facility survey process (on a national and 
     State-specific basis).
       (5) On a State-specific basis, the services available 
     through the State long-term care ombudsman for such State.

     SEC. 6104. REPORTING OF EXPENDITURES.

       Section 1888 of the Social Security Act (42 U.S.C. 1395yy) 
     is amended by adding at the end the following new subsection:
       ``(f) Reporting of Direct Care Expenditures.--
       ``(1) In general.--For cost reports submitted under this 
     title for cost reporting periods beginning on or after the 
     date that is 2 years after the date of the enactment of this 
     subsection, skilled nursing facilities shall separately 
     report expenditures for wages and benefits for direct care 
     staff (breaking out (at a minimum) registered nurses, 
     licensed professional nurses, certified nurse assistants, and 
     other medical and therapy staff).
       ``(2) Modification of form.--The Secretary, in consultation 
     with private sector accountants experienced with Medicare and 
     Medicaid nursing facility home cost reports, shall redesign 
     such reports to meet the requirement of paragraph (1) not 
     later than 1 year after the date of the enactment of this 
     subsection.
       ``(3) Categorization by functional accounts.--Not later 
     than 30 months after the date of the enactment of this 
     subsection, the Secretary, working in consultation with the 
     Medicare Payment Advisory Commission, the Medicaid and CHIP 
     Payment and Access Commission, the Inspector General of the 
     Department of Health and Human Services, and other expert 
     parties the Secretary determines appropriate, shall take the 
     expenditures listed on cost reports, as modified under 
     paragraph (1), submitted by skilled nursing facilities and 
     categorize such expenditures, regardless of any source of 
     payment for such expenditures, for each skilled nursing 
     facility into the following functional accounts on an annual 
     basis:
       ``(A) Spending on direct care services (including nursing, 
     therapy, and medical services).
       ``(B) Spending on indirect care (including housekeeping and 
     dietary services).
       ``(C) Capital assets (including building and land costs).
       ``(D) Administrative services costs.
       ``(4) Availability of information submitted.--The Secretary 
     shall establish procedures to make information on 
     expenditures submitted under this subsection readily 
     available to interested parties upon request, subject to such 
     requirements as the Secretary may specify under the 
     procedures established under this paragraph.''.

     SEC. 6105. STANDARDIZED COMPLAINT FORM.

       (a) In General.--Section 1128I of the Social Security Act, 
     as added and amended by this Act, is amended by adding at the 
     end the following new subsection:
       ``(f) Standardized Complaint Form.--
       ``(1) Development by the secretary.--The Secretary shall 
     develop a standardized complaint form for use by a resident 
     (or a person acting on the resident's behalf) in filing a 
     complaint with a State survey and certification agency and a 
     State long-term care ombudsman program with respect to a 
     facility.
       ``(2) Complaint forms and resolution processes.--
       ``(A) Complaint forms.--The State must make the 
     standardized complaint form developed under paragraph (1) 
     available upon request to--
       ``(i) a resident of a facility; and
       ``(ii) any person acting on the resident's behalf.
       ``(B) Complaint resolution process.--The State must 
     establish a complaint resolution process in order to ensure 
     that the legal representative of a resident of a facility or 
     other responsible party is not denied access to such resident 
     or otherwise retaliated against if they have complained about 
     the quality of care provided by the facility or other issues 
     relating to the facility. Such complaint resolution process 
     shall include--
       ``(i) procedures to assure accurate tracking of complaints 
     received, including notification to the complainant that a 
     complaint has been received;
       ``(ii) procedures to determine the likely severity of a 
     complaint and for the investigation of the complaint; and
       ``(iii) deadlines for responding to a complaint and for 
     notifying the complainant of the outcome of the 
     investigation.
       ``(3) Rule of construction.--Nothing in this subsection 
     shall be construed as preventing a resident of a facility (or 
     a person acting on the resident's behalf) from submitting a 
     complaint in a manner or format other than by using the 
     standardized complaint form developed under paragraph (1) 
     (including submitting a complaint orally).''.
       (b) Effective Date.--The amendment made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 6106. ENSURING STAFFING ACCOUNTABILITY.

       Section 1128I of the Social Security Act, as added and 
     amended by this Act, is amended by adding at the end the 
     following new subsection:
       ``(g) Submission of Staffing Information Based on Payroll 
     Data in a Uniform Format.--Beginning not later than 2 years 
     after the date of the enactment of this subsection, and after 
     consulting with State long-term care ombudsman programs, 
     consumer advocacy groups, provider stakeholder groups, 
     employees and their representatives, and other parties the 
     Secretary deems appropriate, the Secretary shall require a 
     facility to electronically submit to the Secretary direct 
     care staffing information (including information with respect 
     to agency and contract staff) based on payroll and other 
     verifiable and auditable data in a uniform format (according 
     to specifications established by the Secretary in 
     consultation with such programs, groups, and parties). Such 
     specifications shall require that the information submitted 
     under the preceding sentence--
       ``(1) specify the category of work a certified employee 
     performs (such as whether the employee is a registered nurse, 
     licensed practical nurse, licensed vocational nurse, 
     certified nursing assistant, therapist, or other medical 
     personnel);
       ``(2) include resident census data and information on 
     resident case mix;
       ``(3) include a regular reporting schedule; and
       ``(4) include information on employee turnover and tenure 
     and on the hours of care provided by each category of 
     certified employees referenced in paragraph (1) per resident 
     per day.

     Nothing in this subsection shall be construed as preventing 
     the Secretary from requiring submission of such information 
     with respect to specific categories, such as nursing staff, 
     before other categories of certified employees. Information 
     under this subsection with respect to agency and contract 
     staff shall be kept separate from information on employee 
     staffing.''.

     SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING 
                   SYSTEM.

       (a) Study.--The Comptroller General of the United States 
     (in this section referred to as the ``Comptroller General'') 
     shall conduct a study on the Five-Star Quality Rating System 
     for

[[Page 4362]]

     nursing homes of the Centers for Medicare & Medicaid 
     Services. Such study shall include an analysis of--
       (1) how such system is being implemented;
       (2) any problems associated with such system or its 
     implementation; and
       (3) how such system could be improved.
       (b) Report.--Not later than 2 years after the date of 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report containing the results of the study 
     conducted under subsection (a), together with recommendations 
     for such legislation and administrative action as the 
     Comptroller General determines appropriate.

                     PART II--TARGETING ENFORCEMENT

     SEC. 6111. CIVIL MONEY PENALTIES.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819(h)(2)(B)(ii) of the Social 
     Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended--
       (A) by striking ``Penalties.--The Secretary'' and inserting 
     ``penalties.--

       ``(I) In general.--Subject to subclause (II), the 
     Secretary''; and

       (B) by adding at the end the following new subclauses:

       ``(II) Reduction of civil money penalties in certain 
     circumstances.--Subject to subclause (III), in the case where 
     a facility self-reports and promptly corrects a deficiency 
     for which a penalty was imposed under this clause not later 
     than 10 calendar days after the date of such imposition, the 
     Secretary may reduce the amount of the penalty imposed by not 
     more than 50 percent.
       ``(III) Prohibitions on reduction for certain 
     deficiencies.--

       ``(aa) Repeat deficiencies.--The Secretary may not reduce 
     the amount of a penalty under subclause (II) if the Secretary 
     had reduced a penalty imposed on the facility in the 
     preceding year under such subclause with respect to a repeat 
     deficiency.
       ``(bb) Certain other deficiencies.--The Secretary may not 
     reduce the amount of a penalty under subclause (II) if the 
     penalty is imposed on the facility for a deficiency that is 
     found to result in a pattern of harm or widespread harm, 
     immediately jeopardizes the health or safety of a resident or 
     residents of the facility, or results in the death of a 
     resident of the facility.

       ``(IV) Collection of civil money penalties.--In the case of 
     a civil money penalty imposed under this clause, the 
     Secretary shall issue regulations that--

       ``(aa) subject to item (cc), not later than 30 days after 
     the imposition of the penalty, provide for the facility to 
     have the opportunity to participate in an independent 
     informal dispute resolution process which generates a written 
     record prior to the collection of such penalty;
       ``(bb) in the case where the penalty is imposed for each 
     day of noncompliance, provide that a penalty may not be 
     imposed for any day during the period beginning on the 
     initial day of the imposition of the penalty and ending on 
     the day on which the informal dispute resolution process 
     under item (aa) is completed;
       ``(cc) may provide for the collection of such civil money 
     penalty and the placement of such amounts collected in an 
     escrow account under the direction of the Secretary on the 
     earlier of the date on which the informal dispute resolution 
     process under item (aa) is completed or the date that is 90 
     days after the date of the imposition of the penalty;
       ``(dd) may provide that such amounts collected are kept in 
     such account pending the resolution of any subsequent 
     appeals;
       ``(ee) in the case where the facility successfully appeals 
     the penalty, may provide for the return of such amounts 
     collected (plus interest) to the facility; and
       ``(ff) in the case where all such appeals are unsuccessful, 
     may provide that some portion of such amounts collected may 
     be used to support activities that benefit residents, 
     including assistance to support and protect residents of a 
     facility that closes (voluntarily or involuntarily) or is 
     decertified (including offsetting costs of relocating 
     residents to home and community-based settings or another 
     facility), projects that support resident and family councils 
     and other consumer involvement in assuring quality care in 
     facilities, and facility improvement initiatives approved by 
     the Secretary (including joint training of facility staff and 
     surveyors, technical assistance for facilities implementing 
     quality assurance programs, the appointment of temporary 
     management firms, and other activities approved by the 
     Secretary).''.
       (2) Conforming amendment.--The second sentence of section 
     1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-
     3(h)(5)) is amended by inserting ``(ii)(IV),'' after 
     ``(i),''.
       (b) Nursing Facilities.--
       (1) In general.--Section 1919(h)(3)(C)(ii) of the Social 
     Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended--
       (A) by striking ``Penalties.--The Secretary'' and inserting 
     ``penalties.--

       ``(I) In general.--Subject to subclause (II), the 
     Secretary''; and

       (B) by adding at the end the following new subclauses:

       ``(II) Reduction of civil money penalties in certain 
     circumstances.--Subject to subclause (III), in the case where 
     a facility self-reports and promptly corrects a deficiency 
     for which a penalty was imposed under this clause not later 
     than 10 calendar days after the date of such imposition, the 
     Secretary may reduce the amount of the penalty imposed by not 
     more than 50 percent.
       ``(III) Prohibitions on reduction for certain 
     deficiencies.--

       ``(aa) Repeat deficiencies.--The Secretary may not reduce 
     the amount of a penalty under subclause (II) if the Secretary 
     had reduced a penalty imposed on the facility in the 
     preceding year under such subclause with respect to a repeat 
     deficiency.
       ``(bb) Certain other deficiencies.--The Secretary may not 
     reduce the amount of a penalty under subclause (II) if the 
     penalty is imposed on the facility for a deficiency that is 
     found to result in a pattern of harm or widespread harm, 
     immediately jeopardizes the health or safety of a resident or 
     residents of the facility, or results in the death of a 
     resident of the facility.

       ``(IV) Collection of civil money penalties.--In the case of 
     a civil money penalty imposed under this clause, the 
     Secretary shall issue regulations that--

       ``(aa) subject to item (cc), not later than 30 days after 
     the imposition of the penalty, provide for the facility to 
     have the opportunity to participate in an independent 
     informal dispute resolution process which generates a written 
     record prior to the collection of such penalty;
       ``(bb) in the case where the penalty is imposed for each 
     day of noncompliance, provide that a penalty may not be 
     imposed for any day during the period beginning on the 
     initial day of the imposition of the penalty and ending on 
     the day on which the informal dispute resolution process 
     under item (aa) is completed;
       ``(cc) may provide for the collection of such civil money 
     penalty and the placement of such amounts collected in an 
     escrow account under the direction of the Secretary on the 
     earlier of the date on which the informal dispute resolution 
     process under item (aa) is completed or the date that is 90 
     days after the date of the imposition of the penalty;
       ``(dd) may provide that such amounts collected are kept in 
     such account pending the resolution of any subsequent 
     appeals;
       ``(ee) in the case where the facility successfully appeals 
     the penalty, may provide for the return of such amounts 
     collected (plus interest) to the facility; and
       ``(ff) in the case where all such appeals are unsuccessful, 
     may provide that some portion of such amounts collected may 
     be used to support activities that benefit residents, 
     including assistance to support and protect residents of a 
     facility that closes (voluntarily or involuntarily) or is 
     decertified (including offsetting costs of relocating 
     residents to home and community-based settings or another 
     facility), projects that support resident and family councils 
     and other consumer involvement in assuring quality care in 
     facilities, and facility improvement initiatives approved by 
     the Secretary (including joint training of facility staff and 
     surveyors, technical assistance for facilities implementing 
     quality assurance programs, the appointment of temporary 
     management firms, and other activities approved by the 
     Secretary).''.
       (2) Conforming amendment.--Section 1919(h)(5)(8) of the 
     Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by 
     inserting ``(ii)(IV),'' after ``(i),''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 6112. NATIONAL INDEPENDENT MONITOR DEMONSTRATION 
                   PROJECT.

       (a) Establishment.--
       (1) In general.--The Secretary, in consultation with the 
     Inspector General of the Department of Health and Human 
     Services, shall conduct a demonstration project to develop, 
     test, and implement an independent monitor program to oversee 
     interstate and large intrastate chains of skilled nursing 
     facilities and nursing facilities.
       (2) Selection.--The Secretary shall select chains of 
     skilled nursing facilities and nursing facilities described 
     in paragraph (1) to participate in the demonstration project 
     under this section from among those chains that submit an 
     application to the Secretary at such time, in such manner, 
     and containing such information as the Secretary may require.
       (3) Duration.--The Secretary shall conduct the 
     demonstration project under this section for a 2-year period.
       (4) Implementation.--The Secretary shall implement the 
     demonstration project under this section not later than 1 
     year after the date of the enactment of this Act.
       (b) Requirements.--The Secretary shall evaluate chains 
     selected to participate in the demonstration project under 
     this section based on criteria selected by the Secretary, 
     including where evidence suggests that a number of the 
     facilities of the chain are experiencing serious safety and 
     quality of care problems. Such criteria may include the 
     evaluation of a chain that includes a number of facilities 
     participating in the ``Special Focus Facility'' program (or a 
     successor program) or multiple facilities with a record of 
     repeated serious safety and quality of care deficiencies.
       (c) Responsibilities.--An independent monitor that enters 
     into a contract with the Secretary to participate in the 
     conduct of the demonstration project under this section 
     shall--
       (1) conduct periodic reviews and prepare root-cause quality 
     and deficiency analyses of a chain to assess if facilities of 
     the chain are in compliance with State and Federal laws and 
     regulations applicable to the facilities;
       (2) conduct sustained oversight of the efforts of the 
     chain, whether publicly or privately held, to achieve 
     compliance by facilities of the chain with State and Federal 
     laws and regulations applicable to the facilities;
       (3) analyze the management structure, distribution of 
     expenditures, and nurse staffing levels of facilities of the 
     chain in relation to resident census, staff turnover rates, 
     and tenure;

[[Page 4363]]

       (4) report findings and recommendations with respect to 
     such reviews, analyses, and oversight to the chain and 
     facilities of the chain, to the Secretary, and to relevant 
     States; and
       (5) publish the results of such reviews, analyses, and 
     oversight.
       (d) Implementation of Recommendations.--
       (1) Receipt of finding by chain.--Not later than 10 days 
     after receipt of a finding of an independent monitor under 
     subsection (c)(4), a chain participating in the demonstration 
     project shall submit to the independent monitor a report--
       (A) outlining corrective actions the chain will take to 
     implement the recommendations in such report; or
       (B) indicating that the chain will not implement such 
     recommendations, and why it will not do so.
       (2) Receipt of report by independent monitor.--Not later 
     than 10 days after receipt of a report submitted by a chain 
     under paragraph (1), an independent monitor shall finalize 
     its recommendations and submit a report to the chain and 
     facilities of the chain, the Secretary, and the State or 
     States, as appropriate, containing such final 
     recommendations.
       (e) Cost of Appointment.--A chain shall be responsible for 
     a portion of the costs associated with the appointment of 
     independent monitors under the demonstration project under 
     this section. The chain shall pay such portion to the 
     Secretary (in an amount and in accordance with procedures 
     established by the Secretary).
       (f) Waiver Authority.--The Secretary may waive such 
     requirements of titles XVIII and XIX of the Social Security 
     Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be 
     necessary for the purpose of carrying out the demonstration 
     project under this section.
       (g) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.
       (h) Definitions.--In this section:
       (1) Additional disclosable party.--The term ``additional 
     disclosable party'' has the meaning given such term in 
     section 1124(c)(5)(A) of the Social Security Act, as added by 
     section 4201(a).
       (2) Facility.--The term ``facility'' means a skilled 
     nursing facility or a nursing facility.
       (3) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services, acting through the Assistant 
     Secretary for Planning and Evaluation.
       (5) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395(a)).
       (i) Evaluation and Report.--
       (1) Evaluation.--The Secretary, in consultation with the 
     Inspector General of the Department of Health and Human 
     Services, shall evaluate the demonstration project conducted 
     under this section.
       (2) Report.--Not later than 180 days after the completion 
     of the demonstration project under this section, the 
     Secretary shall submit to Congress a report containing the 
     results of the evaluation conducted under paragraph (1), 
     together with recommendations--
       (A) as to whether the independent monitor program should be 
     established on a permanent basis;
       (B) if the Secretary recommends that such program be so 
     established, on appropriate procedures and mechanisms for 
     such establishment; and
       (C) for such legislation and administrative action as the 
     Secretary determines appropriate.

     SEC. 6113. NOTIFICATION OF FACILITY CLOSURE.

       (a) In General.--Section 1128I of the Social Security Act, 
     as added and amended by this Act, is amended by adding at the 
     end the following new subsection:
       ``(h) Notification of Facility Closure.--
       ``(1) In general.--Any individual who is the administrator 
     of a facility must--
       ``(A) submit to the Secretary, the State long-term care 
     ombudsman, residents of the facility, and the legal 
     representatives of such residents or other responsible 
     parties, written notification of an impending closure--
       ``(i) subject to clause (ii), not later than the date that 
     is 60 days prior to the date of such closure; and
       ``(ii) in the case of a facility where the Secretary 
     terminates the facility's participation under this title, not 
     later than the date that the Secretary determines 
     appropriate;
       ``(B) ensure that the facility does not admit any new 
     residents on or after the date on which such written 
     notification is submitted; and
       ``(C) include in the notice a plan for the transfer and 
     adequate relocation of the residents of the facility by a 
     specified date prior to closure that has been approved by the 
     State, including assurances that the residents will be 
     transferred to the most appropriate facility or other setting 
     in terms of quality, services, and location, taking into 
     consideration the needs, choice, and best interests of each 
     resident.
       ``(2) Relocation.--
       ``(A) In general.--The State shall ensure that, before a 
     facility closes, all residents of the facility have been 
     successfully relocated to another facility or an alternative 
     home and community-based setting.
       ``(B) Continuation of payments until residents relocated.--
     The Secretary may, as the Secretary determines appropriate, 
     continue to make payments under this title with respect to 
     residents of a facility that has submitted a notification 
     under paragraph (1) during the period beginning on the date 
     such notification is submitted and ending on the date on 
     which the resident is successfully relocated.
       ``(3) Sanctions.--Any individual who is the administrator 
     of a facility that fails to comply with the requirements of 
     paragraph (1)--
       ``(A) shall be subject to a civil monetary penalty of up to 
     $100,000;
       ``(B) may be subject to exclusion from participation in any 
     Federal health care program (as defined in section 1128B(f)); 
     and
       ``(C) shall be subject to any other penalties that may be 
     prescribed by law.
       ``(4) Procedure.--The provisions of section 1128A (other 
     than subsections (a) and (b) and the second sentence of 
     subsection (f)) shall apply to a civil money penalty or 
     exclusion under paragraph (3) in the same manner as such 
     provisions apply to a penalty or proceeding under section 
     1128A(a).''.
       (b) Conforming Amendments.--Section 1819(h)(4) of the 
     Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
       (1) in the first sentence, by striking ``the Secretary 
     shall terminate'' and inserting ``the Secretary, subject to 
     section 1128I(h), shall terminate''; and
       (2) in the second sentence, by striking ``subsection 
     (c)(2)'' and inserting ``subsection (c)(2) and section 
     1128I(h)''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 6114. NATIONAL DEMONSTRATION PROJECTS ON CULTURE CHANGE 
                   AND USE OF INFORMATION TECHNOLOGY IN NURSING 
                   HOMES.

       (a) In General.--The Secretary shall conduct 2 
     demonstration projects, 1 for the development of best 
     practices in skilled nursing facilities and nursing 
     facilities that are involved in the culture change movement 
     (including the development of resources for facilities to 
     find and access funding in order to undertake culture change) 
     and 1 for the development of best practices in skilled 
     nursing facilities and nursing facilities for the use of 
     information technology to improve resident care.
       (b) Conduct of Demonstration Projects.--
       (1) Grant award.--Under each demonstration project 
     conducted under this section, the Secretary shall award 1 or 
     more grants to facility-based settings for the development of 
     best practices described in subsection (a) with respect to 
     the demonstration project involved. Such award shall be made 
     on a competitive basis and may be allocated in 1 lump-sum 
     payment.
       (2) Consideration of special needs of residents.--Each 
     demonstration project conducted under this section shall take 
     into consideration the special needs of residents of skilled 
     nursing facilities and nursing facilities who have cognitive 
     impairment, including dementia.
       (c) Duration and Implementation.--
       (1) Duration.--The demonstration projects shall each be 
     conducted for a period not to exceed 3 years.
       (2) Implementation.--The demonstration projects shall each 
     be implemented not later than 1 year after the date of the 
     enactment of this Act.
       (d) Definitions.--In this section:
       (1) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (2) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (3) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395(a)).
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.
       (f) Report.--Not later than 9 months after the completion 
     of the demonstration project, the Secretary shall submit to 
     Congress a report on such project, together with 
     recommendations for such legislation and administrative 
     action as the Secretary determines appropriate.

                   PART III--IMPROVING STAFF TRAINING

     SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819(f)(2)(A)(i)(I) of the Social 
     Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by 
     inserting ``(including, in the case of initial training and, 
     if the Secretary determines appropriate, in the case of 
     ongoing training, dementia management training, and patient 
     abuse prevention training'' before ``, (II)''.
         (2) Clarification of definition of nurse aide.--Section 
     1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i-
     3(b)(5)(F)) is amended by adding at the end the following 
     flush sentence:
     ``Such term includes an individual who provides such services 
     through an agency or under a contract with the facility.''.
         (b) Nursing Facilities.--
         (1) In general.--Section 1919(f)(2)(A)(i)(I) of the 
     Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is 
     amended by inserting ``(including, in the case of initial 
     training and, if the Secretary determines appropriate, in the 
     case of ongoing training, dementia management training, and 
     patient abuse prevention training'' before ``, (II)''.
         (2) Clarification of definition of nurse aide.--Section 
     1919(b)(5)(F) of the Social Security Act (42 U.S.C. 
     1396r(b)(5)(F)) is amended by adding at the end the following 
     flush sentence:


[[Page 4364]]


     ``Such term includes an individual who provides such services 
     through an agency or under a contract with the facility.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

Subtitle C--Nationwide Program for National and State Background Checks 
  on Direct Patient Access Employees of Long-term Care Facilities and 
                               Providers

     SEC. 6201. NATIONWIDE PROGRAM FOR NATIONAL AND STATE 
                   BACKGROUND CHECKS ON DIRECT PATIENT ACCESS 
                   EMPLOYEES OF LONG-TERM CARE FACILITIES AND 
                   PROVIDERS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary''), shall 
     establish a program to identify efficient, effective, and 
     economical procedures for long term care facilities or 
     providers to conduct background checks on prospective direct 
     patient access employees on a nationwide basis (in this 
     subsection, such program shall be referred to as the 
     ``nationwide program''). Except for the following 
     modifications, the Secretary shall carry out the nationwide 
     program under similar terms and conditions as the pilot 
     program under section 307 of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173; 117 Stat. 2257), including the prohibition on hiring 
     abusive workers and the authorization of the imposition of 
     penalties by a participating State under subsection (b)(3)(A) 
     and (b)(6), respectively, of such section 307:
       (1) Agreements.--
       (A) Newly participating states.--The Secretary shall enter 
     into agreements with each State--
       (i) that the Secretary has not entered into an agreement 
     with under subsection (c)(1) of such section 307;
       (ii) that agrees to conduct background checks under the 
     nationwide program on a Statewide basis; and
       (iii) that submits an application to the Secretary 
     containing such information and at such time as the Secretary 
     may specify.
       (B) Certain previously participating states.--The Secretary 
     shall enter into agreements with each State--
       (i) that the Secretary has entered into an agreement with 
     under such subsection (c)(1), but only in the case where such 
     agreement did not require the State to conduct background 
     checks under the program established under subsection (a) of 
     such section 307 on a Statewide basis;
       (ii) that agrees to conduct background checks under the 
     nationwide program on a Statewide basis; and
       (iii) that submits an application to the Secretary 
     containing such information and at such time as the Secretary 
     may specify.
       (2) Nonapplication of selection criteria.--The selection 
     criteria required under subsection (c)(3)(B) of such section 
     307 shall not apply.
       (3) Required fingerprint check as part of criminal history 
     background check.--The procedures established under 
     subsection (b)(1) of such section 307 shall--
       (A) require that the long-term care facility or provider 
     (or the designated agent of the long-term care facility or 
     provider) obtain State and national criminal history 
     background checks on the prospective employee through such 
     means as the Secretary determines appropriate, efficient, and 
     effective that utilize a search of State-based abuse and 
     neglect registries and databases, including the abuse and 
     neglect registries of another State in the case where a 
     prospective employee previously resided in that State, State 
     criminal history records, the records of any proceedings in 
     the State that may contain disqualifying information about 
     prospective employees (such as proceedings conducted by State 
     professional licensing and disciplinary boards and State 
     Medicaid Fraud Control Units), and Federal criminal history 
     records, including a fingerprint check using the Integrated 
     Automated Fingerprint Identification System of the Federal 
     Bureau of Investigation;
       (B) require States to describe and test methods that reduce 
     duplicative fingerprinting, including providing for the 
     development of ``rap back'' capability by the State such 
     that, if a direct patient access employee of a long-term care 
     facility or provider is convicted of a crime following the 
     initial criminal history background check conducted with 
     respect to such employee, and the employee's fingerprints 
     match the prints on file with the State law enforcement 
     department, the department will immediately inform the State 
     and the State will immediately inform the long-term care 
     facility or provider which employs the direct patient access 
     employee of such conviction; and
       (C) require that criminal history background checks 
     conducted under the nationwide program remain valid for a 
     period of time specified by the Secretary.
       (4) State requirements.--An agreement entered into under 
     paragraph (1) shall require that a participating State--
       (A) be responsible for monitoring compliance with the 
     requirements of the nationwide program;
       (B) have procedures in place to--
       (i) conduct screening and criminal history background 
     checks under the nationwide program in accordance with the 
     requirements of this section;
       (ii) monitor compliance by long-term care facilities and 
     providers with the procedures and requirements of the 
     nationwide program;
       (iii) as appropriate, provide for a provisional period of 
     employment by a long-term care facility or provider of a 
     direct patient access employee, not to exceed 60 days, 
     pending completion of the required criminal history 
     background check and, in the case where the employee has 
     appealed the results of such background check, pending 
     completion of the appeals process, during which the employee 
     shall be subject to direct on-site supervision (in accordance 
     with procedures established by the State to ensure that a 
     long-term care facility or provider furnishes such direct on-
     site supervision);
       (iv) provide an independent process by which a provisional 
     employee or an employee may appeal or dispute the accuracy of 
     the information obtained in a background check performed 
     under the nationwide program, including the specification of 
     criteria for appeals for direct patient access employees 
     found to have disqualifying information which shall include 
     consideration of the passage of time, extenuating 
     circumstances, demonstration of rehabilitation, and relevancy 
     of the particular disqualifying information with respect to 
     the current employment of the individual;
       (v) provide for the designation of a single State agency as 
     responsible for--

       (I) overseeing the coordination of any State and national 
     criminal history background checks requested by a long-term 
     care facility or provider (or the designated agent of the 
     long-term care facility or provider) utilizing a search of 
     State and Federal criminal history records, including a 
     fingerprint check of such records;
       (II) overseeing the design of appropriate privacy and 
     security safeguards for use in the review of the results of 
     any State or national criminal history background checks 
     conducted regarding a prospective direct patient access 
     employee to determine whether the employee has any conviction 
     for a relevant crime;
       (III) immediately reporting to the long-term care facility 
     or provider that requested the criminal history background 
     check the results of such review; and
       (IV) in the case of an employee with a conviction for a 
     relevant crime that is subject to reporting under section 
     1128E of the Social Security Act (42 U.S.C. 1320a-7e), 
     reporting the existence of such conviction to the database 
     established under that section;

       (vi) determine which individuals are direct patient access 
     employees (as defined in paragraph (6)(B)) for purposes of 
     the nationwide program;
       (vii) as appropriate, specify offenses, including 
     convictions for violent crimes, for purposes of the 
     nationwide program; and
       (viii) describe and test methods that reduce duplicative 
     fingerprinting, including providing for the development of 
     ``rap back'' capability such that, if a direct patient access 
     employee of a long-term care facility or provider is 
     convicted of a crime following the initial criminal history 
     background check conducted with respect to such employee, and 
     the employee's fingerprints match the prints on file with the 
     State law enforcement department--

       (I) the department will immediately inform the State agency 
     designated under clause (v) and such agency will immediately 
     inform the facility or provider which employs the direct 
     patient access employee of such conviction; and
       (II) the State will provide, or will require the facility 
     to provide, to the employee a copy of the results of the 
     criminal history background check conducted with respect to 
     the employee at no charge in the case where the individual 
     requests such a copy.

       (5) Payments.--
       (A) Newly participating states.--
       (i) In general.--As part of the application submitted by a 
     State under paragraph (1)(A)(iii), the State shall guarantee, 
     with respect to the costs to be incurred by the State in 
     carrying out the nationwide program, that the State will make 
     available (directly or through donations from public or 
     private entities) a particular amount of non-Federal 
     contributions, as a condition of receiving the Federal match 
     under clause (ii).
       (ii) Federal match.--The payment amount to each State that 
     the Secretary enters into an agreement with under paragraph 
     (1)(A) shall be 3 times the amount that the State guarantees 
     to make available under clause (i), except that in no case 
     may the payment amount exceed $3,000,000.
       (B) Previously participating states.--
       (i) In general.--As part of the application submitted by a 
     State under paragraph (1)(B)(iii), the State shall guarantee, 
     with respect to the costs to be incurred by the State in 
     carrying out the nationwide program, that the State will make 
     available (directly or through donations from public or 
     private entities) a particular amount of non-Federal 
     contributions, as a condition of receiving the Federal match 
     under clause (ii).
       (ii) Federal match.--The payment amount to each State that 
     the Secretary enters into an agreement with under paragraph 
     (1)(B) shall be 3 times the amount that the State guarantees 
     to make available under clause (i), except that in no case 
     may the payment amount exceed $1,500,000.
       (6) Definitions.--Under the nationwide program:
       (A) Conviction for a relevant crime.--The term ``conviction 
     for a relevant crime'' means any Federal or State criminal 
     conviction for--
       (i) any offense described in section 1128(a) of the Social 
     Security Act (42 U.S.C. 1320a-7); or
       (ii) such other types of offenses as a participating State 
     may specify for purposes of conducting the program in such 
     State.
       (B) Disqualifying information.--The term ``disqualifying 
     information'' means a conviction

[[Page 4365]]

     for a relevant crime or a finding of patient or resident 
     abuse.
       (C) Finding of patient or resident abuse.--The term 
     ``finding of patient or resident abuse'' means any 
     substantiated finding by a State agency under section 
     1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security Act (42 
     U.S.C. 1395i-3(g)(1)(C), 1396r(g)(1)(C)) or a Federal agency 
     that a direct patient access employee has committed--
       (i) an act of patient or resident abuse or neglect or a 
     misappropriation of patient or resident property; or
       (ii) such other types of acts as a participating State may 
     specify for purposes of conducting the program in such State.
       (D) Direct patient access employee.--The term ``direct 
     patient access employee'' means any individual who has access 
     to a patient or resident of a long-term care facility or 
     provider through employment or through a contract with such 
     facility or provider and has duties that involve (or may 
     involve) one-on-one contact with a patient or resident of the 
     facility or provider, as determined by the State for purposes 
     of the nationwide program. Such term does not include a 
     volunteer unless the volunteer has duties that are equivalent 
     to the duties of a direct patient access employee and those 
     duties involve (or may involve) one-on-one contact with a 
     patient or resident of the long-term care facility or 
     provider.
       (E) Long-term care facility or provider.--The term ``long-
     term care facility or provider'' means the following 
     facilities or providers which receive payment for services 
     under title XVIII or XIX of the Social Security Act:
       (i) A skilled nursing facility (as defined in section 
     1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a))).
       (ii) A nursing facility (as defined in section 1919(a) of 
     such Act (42 U.S.C. 1396r(a))).
       (iii) A home health agency.
       (iv) A provider of hospice care (as defined in section 
     1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))).
       (v) A long-term care hospital (as described in section 
     1886(d)(1)(B)(iv) of such Act (42 U.S.C. 
     1395ww(d)(1)(B)(iv))).
       (vi) A provider of personal care services.
       (vii) A provider of adult day care.
       (viii) A residential care provider that arranges for, or 
     directly provides, long-term care services, including an 
     assisted living facility that provides a level of care 
     established by the Secretary.
       (ix) An intermediate care facility for the mentally 
     retarded (as defined in section 1905(d) of such Act (42 
     U.S.C. 1396d(d))).
       (x) Any other facility or provider of long-term care 
     services under such titles as the participating State 
     determines appropriate.
       (7) Evaluation and report.--
       (A) Evaluation.--
       (i) In general.--The Inspector General of the Department of 
     Health and Human Services shall conduct an evaluation of the 
     nationwide program.
       (ii) Inclusion of specific topics.--The evaluation 
     conducted under clause (i) shall include the following:

       (I) A review of the various procedures implemented by 
     participating States for long-term care facilities or 
     providers, including staffing agencies, to conduct background 
     checks of direct patient access employees under the 
     nationwide program and identification of the most 
     appropriate, efficient, and effective procedures for 
     conducting such background checks.
       (II) An assessment of the costs of conducting such 
     background checks (including start up and administrative 
     costs).
       (III) A determination of the extent to which conducting 
     such background checks leads to any unintended consequences, 
     including a reduction in the available workforce for long-
     term care facilities or providers.
       (IV) An assessment of the impact of the nationwide program 
     on reducing the number of incidents of neglect, abuse, and 
     misappropriation of resident property to the extent 
     practicable.
       (V) An evaluation of other aspects of the nationwide 
     program, as determined appropriate by the Secretary.

       (B) Report.--Not later than 180 days after the completion 
     of the nationwide program, the Inspector General of the 
     Department of Health and Human Services shall submit a report 
     to Congress containing the results of the evaluation 
     conducted under subparagraph (A).
       (b) Funding.--
       (1) Notification.--The Secretary of Health and Human 
     Services shall notify the Secretary of the Treasury of the 
     amount necessary to carry out the nationwide program under 
     this section for the period of fiscal years 2010 through 
     2012, except that in no case shall such amount exceed 
     $160,000,000.
       (2) Transfer of funds.--
       (A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, the Secretary of the Treasury shall 
     provide for the transfer to the Secretary of Health and Human 
     Services of the amount specified as necessary to carry out 
     the nationwide program under paragraph (1). Such amount shall 
     remain available until expended.
       (B) Reservation of funds for conduct of evaluation.--The 
     Secretary may reserve not more than $3,000,000 of the amount 
     transferred under subparagraph (A) to provide for the conduct 
     of the evaluation under subsection (a)(7)(A).

             Subtitle D--Patient-Centered Outcomes Research

     SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH.

       (a) In General.--Title XI of the Social Security Act (42 
     U.S.C. 1301 et seq.) is amended by adding at the end the 
     following new part:

         ``Part D--Comparative Clinical Effectiveness Research


             ``comparative clinical effectiveness research

       ``Sec. 1181.  (a) Definitions.--In this section:
       ``(1) Board.--The term `Board' means the Board of Governors 
     established under subsection (f).
       ``(2) Comparative clinical effectiveness research; 
     research.--
       ``(A) In general.--The terms `comparative clinical 
     effectiveness research' and `research' mean research 
     evaluating and comparing health outcomes and the clinical 
     effectiveness, risks, and benefits of 2 or more medical 
     treatments, services, and items described in subparagraph 
     (B).
       ``(B) Medical treatments, services, and items described.--
     The medical treatments, services, and items described in this 
     subparagraph are health care interventions, protocols for 
     treatment, care management, and delivery, procedures, medical 
     devices, diagnostic tools, pharmaceuticals (including drugs 
     and biologicals), integrative health practices, and any other 
     strategies or items being used in the treatment, management, 
     and diagnosis of, or prevention of illness or injury in, 
     individuals.
       ``(3) Conflict of interest.--The term `conflict of 
     interest' means an association, including a financial or 
     personal association, that have the potential to bias or have 
     the appearance of biasing an individual's decisions in 
     matters related to the Institute or the conduct of activities 
     under this section.
       ``(4) Real conflict of interest.--The term `real conflict 
     of interest' means any instance where a member of the Board, 
     the methodology committee established under subsection 
     (d)(6), or an advisory panel appointed under subsection 
     (d)(4), or a close relative of such member, has received or 
     could receive either of the following:
       ``(A) A direct financial benefit of any amount deriving 
     from the result or findings of a study conducted under this 
     section.
       ``(B) A financial benefit from individuals or companies 
     that own or manufacture medical treatments, services, or 
     items to be studied under this section that in the aggregate 
     exceeds $10,000 per year. For purposes of the preceding 
     sentence, a financial benefit includes honoraria, fees, 
     stock, or other financial benefit and the current value of 
     the member or close relative's already existing stock 
     holdings, in addition to any direct financial benefit 
     deriving from the results or findings of a study conducted 
     under this section.
       ``(b) Patient-Centered Outcomes Research Institute.--
       ``(1) Establishment.--There is authorized to be established 
     a nonprofit corporation, to be known as the `Patient-Centered 
     Outcomes Research Institute' (referred to in this section as 
     the `Institute') which is neither an agency nor establishment 
     of the United States Government.
       ``(2) Application of provisions.--The Institute shall be 
     subject to the provisions of this section, and, to the extent 
     consistent with this section, to the District of Columbia 
     Nonprofit Corporation Act.
       ``(3) Funding of comparative clinical effectiveness 
     research.--For fiscal year 2010 and each subsequent fiscal 
     year, amounts in the Patient-Centered Outcomes Research Trust 
     Fund (referred to in this section as the `PCORTF') under 
     section 9511 of the Internal Revenue Code of 1986 shall be 
     available, without further appropriation, to the Institute to 
     carry out this section.
       ``(c) Purpose.--The purpose of the Institute is to assist 
     patients, clinicians, purchasers, and policy-makers in making 
     informed health decisions by advancing the quality and 
     relevance of evidence concerning the manner in which 
     diseases, disorders, and other health conditions can 
     effectively and appropriately be prevented, diagnosed, 
     treated, monitored, and managed through research and evidence 
     synthesis that considers variations in patient 
     subpopulations, and the dissemination of research findings 
     with respect to the relative health outcomes, clinical 
     effectiveness, and appropriateness of the medical treatments, 
     services, and items described in subsection (a)(2)(B).
       ``(d) Duties.--
       ``(1) Identifying research priorities and establishing 
     research project agenda.--
       ``(A) Identifying research priorities.--The Institute shall 
     identify national priorities for research, taking into 
     account factors of disease incidence, prevalence, and burden 
     in the United States (with emphasis on chronic conditions), 
     gaps in evidence in terms of clinical outcomes, practice 
     variations and health disparities in terms of delivery and 
     outcomes of care, the potential for new evidence to improve 
     patient health, well-being, and the quality of care, the 
     effect on national expenditures associated with a health care 
     treatment, strategy, or health conditions, as well as patient 
     needs, outcomes, and preferences, the relevance to patients 
     and clinicians in making informed health decisions, and 
     priorities in the National Strategy for quality care 
     established under section 399H of the Public Health Service 
     Act that are consistent with this section.
       ``(B) Establishing research project agenda.--The Institute 
     shall establish and update a research project agenda for 
     research to address the priorities identified under 
     subparagraph (A), taking into consideration the types of 
     research

[[Page 4366]]

     that might address each priority and the relative value 
     (determined based on the cost of conducting research compared 
     to the potential usefulness of the information produced by 
     research) associated with the different types of research, 
     and such other factors as the Institute determines 
     appropriate.
       ``(2) Carrying out research project agenda.--
       ``(A) Research.--The Institute shall carry out the research 
     project agenda established under paragraph (1)(B) in 
     accordance with the methodological standards adopted under 
     paragraph (9) using methods, including the following:
       ``(i) Systematic reviews and assessments of existing and 
     future research and evidence including original research 
     conducted subsequent to the date of the enactment of this 
     section.
       ``(ii) Primary research, such as randomized clinical 
     trials, molecularly informed trials, and observational 
     studies.
       ``(iii) Any other methodologies recommended by the 
     methodology committee established under paragraph (6) that 
     are adopted by the Board under paragraph (9).
       ``(B) Contracts for the management of funding and conduct 
     of research.--
       ``(i) Contracts.--

       ``(I) In general.--In accordance with the research project 
     agenda established under paragraph (1)(B), the Institute 
     shall enter into contracts for the management of funding and 
     conduct of research in accordance with the following:

       ``(aa) Appropriate agencies and instrumentalities of the 
     Federal Government.
       ``(bb) Appropriate academic research, private sector 
     research, or study-conducting entities.

       ``(II) Preference.--In entering into contracts under 
     subclause (I), the Institute shall give preference to the 
     Agency for Healthcare Research and Quality and the National 
     Institutes of Health, but only if the research to be 
     conducted or managed under such contract is authorized by the 
     governing statutes of such Agency or Institutes.

       ``(ii) Conditions for contracts.--A contract entered into 
     under this subparagraph shall require that the agency, 
     instrumentality, or other entity--

       ``(I) abide by the transparency and conflicts of interest 
     requirements under subsection (h) that apply to the Institute 
     with respect to the research managed or conducted under such 
     contract;
       ``(II) comply with the methodological standards adopted 
     under paragraph (9) with respect to such research;
       ``(III) consult with the expert advisory panels for 
     clinical trials and rare disease appointed under clauses (ii) 
     and (iii), respectively, of paragraph (4)(A);
       ``(IV) subject to clause (iv), permit a researcher who 
     conducts original research under the contract for the agency, 
     instrumentality, or other entity to have such research 
     published in a peer-reviewed journal or other publication;
       ``(V) have appropriate processes in place to manage data 
     privacy and meet ethical standards for the research;
       ``(VI) comply with the requirements of the Institute for 
     making the information available to the public under 
     paragraph (8); and
       ``(VII) comply with other terms and conditions determined 
     necessary by the Institute to carry out the research agenda 
     adopted under paragraph (2).

       ``(iii) Coverage of copayments or coinsurance.--A contract 
     entered into under this subparagraph may allow for the 
     coverage of copayments or coinsurance, or allow for other 
     appropriate measures, to the extent that such coverage or 
     other measures are necessary to preserve the validity of a 
     research project, such as in the case where the research 
     project must be blinded.
       ``(iv) Requirements for publication of research.--Any 
     research published under clause (ii)(IV) shall be within the 
     bounds of and entirely consistent with the evidence and 
     findings produced under the contract with the Institute under 
     this subparagraph. If the Institute determines that those 
     requirements are not met, the Institute shall not enter into 
     another contract with the agency, instrumentality, or entity 
     which managed or conducted such research for a period 
     determined appropriate by the Institute (but not less than 5 
     years).
       ``(C) Review and update of evidence.--The Institute shall 
     review and update evidence on a periodic basis as 
     appropriate.
       ``(D) Taking into account potential differences.--Research 
     shall be designed, as appropriate, to take into account the 
     potential for differences in the effectiveness of health care 
     treatments, services, and items as used with various 
     subpopulations, such as racial and ethnic minorities, women, 
     age, and groups of individuals with different comorbidities, 
     genetic and molecular sub-types, or quality of life 
     preferences and include members of such subpopulations as 
     subjects in the research as feasible and appropriate.
       ``(E) Differences in treatment modalities.--Research shall 
     be designed, as appropriate, to take into account different 
     characteristics of treatment modalities that may affect 
     research outcomes, such as the phase of the treatment 
     modality in the innovation cycle and the impact of the skill 
     of the operator of the treatment modality.
       ``(3) Data collection.--
       ``(A) In general.--The Secretary shall, with appropriate 
     safeguards for privacy, make available to the Institute such 
     data collected by the Centers for Medicare & Medicaid 
     Services under the programs under titles XVIII, XIX, and XXI, 
     as well as provide access to the data networks developed 
     under section 937(f) of the Public Health Service Act, as the 
     Institute and its contractors may require to carry out this 
     section. The Institute may also request and obtain data from 
     Federal, State, or private entities, including data from 
     clinical databases and registries.
       ``(B) Use of data.--The Institute shall only use data 
     provided to the Institute under subparagraph (A) in 
     accordance with laws and regulations governing the release 
     and use of such data, including applicable confidentiality 
     and privacy standards.
       ``(4) Appointing expert advisory panels.--
       ``(A) Appointment.--
       ``(i) In general.--The Institute may appoint permanent or 
     ad hoc expert advisory panels as determined appropriate to 
     assist in identifying research priorities and establishing 
     the research project agenda under paragraph (1) and for other 
     purposes.
       ``(ii) Expert advisory panels for clinical trials.--The 
     Institute shall appoint expert advisory panels in carrying 
     out randomized clinical trials under the research project 
     agenda under paragraph (2)(A)(ii). Such expert advisory 
     panels shall advise the Institute and the agency, 
     instrumentality, or entity conducting the research on the 
     research question involved and the research design or 
     protocol, including important patient subgroups and other 
     parameters of the research. Such panels shall be available as 
     a resource for technical questions that may arise during the 
     conduct of such research.
       ``(iii) Expert advisory panel for rare disease.--In the 
     case of a research study for rare disease, the Institute 
     shall appoint an expert advisory panel for purposes of 
     assisting in the design of the research study and determining 
     the relative value and feasibility of conducting the research 
     study.
       ``(B) Composition.--An expert advisory panel appointed 
     under subparagraph (A) shall include representatives of 
     practicing and research clinicians, patients, and experts in 
     scientific and health services research, health services 
     delivery, and evidence-based medicine who have experience in 
     the relevant topic, and as appropriate, experts in 
     integrative health and primary prevention strategies. The 
     Institute may include a technical expert of each manufacturer 
     or each medical technology that is included under the 
     relevant topic, project, or category for which the panel is 
     established.
       ``(5) Supporting patient and consumer representatives.--The 
     Institute shall provide support and resources to help patient 
     and consumer representatives effectively participate on the 
     Board and expert advisory panels appointed by the Institute 
     under paragraph (4).
       ``(6) Establishing methodology committee.--
       ``(A) In general.--The Institute shall establish a standing 
     methodology committee to carry out the functions described in 
     subparagraph (C).
       ``(B) Appointment and composition.--The methodology 
     committee established under subparagraph (A) shall be 
     composed of not more than 15 members appointed by the 
     Comptroller General of the United States. Members appointed 
     to the methodology committee shall be experts in their 
     scientific field, such as health services research, clinical 
     research, comparative clinical effectiveness research, 
     biostatistics, genomics, and research methodologies. 
     Stakeholders with such expertise may be appointed to the 
     methodology committee. In addition to the members appointed 
     under the first sentence, the Directors of the National 
     Institutes of Health and the Agency for Healthcare Research 
     and Quality (or their designees) shall each be included as 
     members of the methodology committee.
       ``(C) Functions.--Subject to subparagraph (D), the 
     methodology committee shall work to develop and improve the 
     science and methods of comparative clinical effectiveness 
     research by, not later than 18 months after the establishment 
     of the Institute, directly or through subcontract, developing 
     and periodically updating the following:
       ``(i) Methodological standards for research. Such 
     methodological standards shall provide specific criteria for 
     internal validity, generalizability, feasibility, and 
     timeliness of research and for health outcomes measures, risk 
     adjustment, and other relevant aspects of research and 
     assessment with respect to the design of research. Any 
     methodological standards developed and updated under this 
     subclause shall be scientifically based and include methods 
     by which new information, data, or advances in technology are 
     considered and incorporated into ongoing research projects by 
     the Institute, as appropriate. The process for developing and 
     updating such standards shall include input from relevant 
     experts, stakeholders, and decisionmakers, and shall provide 
     opportunities for public comment. Such standards shall also 
     include methods by which patient subpopulations can be 
     accounted for and evaluated in different types of research. 
     As appropriate, such standards shall build on existing work 
     on methodological standards for defined categories of health 
     interventions and for each of the major categories of 
     comparative clinical effectiveness research methods 
     (determined as of the date of enactment of the Patient 
     Protection and Affordable Care Act).
       ``(ii) A translation table that is designed to provide 
     guidance and act as a reference for the Board to determine 
     research methods that are most likely to address each 
     specific research question.

[[Page 4367]]

       ``(D) Consultation and conduct of examinations.--The 
     methodology committee may consult and contract with the 
     Institute of Medicine of the National Academies and academic, 
     nonprofit, or other private and governmental entities with 
     relevant expertise to carry out activities described in 
     subparagraph (C) and may consult with relevant stakeholders 
     to carry out such activities.
       ``(E) Reports.--The methodology committee shall submit 
     reports to the Board on the committee's performance of the 
     functions described in subparagraph (C). Reports shall 
     contain recommendations for the Institute to adopt 
     methodological standards developed and updated by the 
     methodology committee as well as other actions deemed 
     necessary to comply with such methodological standards.
       ``(7) Providing for a peer-review process for primary 
     research.--
       ``(A) In general.--The Institute shall ensure that there is 
     a process for peer review of primary research described in 
     subparagraph (A)(ii) of paragraph (2) that is conducted under 
     such paragraph. Under such process--
       ``(i) evidence from such primary research shall be reviewed 
     to assess scientific integrity and adherence to 
     methodological standards adopted under paragraph (9); and
       ``(ii) a list of the names of individuals contributing to 
     any peer-review process during the preceding year or years 
     shall be made public and included in annual reports in 
     accordance with paragraph (10)(D).
       ``(B) Composition.--Such peer-review process shall be 
     designed in a manner so as to avoid bias and conflicts of 
     interest on the part of the reviewers and shall be composed 
     of experts in the scientific field relevant to the research 
     under review.
       ``(C) Use of existing processes.--
       ``(i) Processes of another entity.--In the case where the 
     Institute enters into a contract or other agreement with 
     another entity for the conduct or management of research 
     under this section, the Institute may utilize the peer-review 
     process of such entity if such process meets the requirements 
     under subparagraphs (A) and (B).
       ``(ii) Processes of appropriate medical journals.--The 
     Institute may utilize the peer-review process of appropriate 
     medical journals if such process meets the requirements under 
     subparagraphs (A) and (B).
       ``(8) Release of research findings.--
       ``(A) In general.--The Institute shall, not later than 90 
     days after the conduct or receipt of research findings under 
     this part, make such research findings available to 
     clinicians, patients, and the general public. The Institute 
     shall ensure that the research findings--
       ``(i) convey the findings of research in a manner that is 
     comprehensible and useful to patients and providers in making 
     health care decisions;
       ``(ii) fully convey findings and discuss considerations 
     specific to certain subpopulations, risk factors, and 
     comorbidities, as appropriate;
       ``(iii) include limitations of the research and what 
     further research may be needed as appropriate;
       ``(iv) not be construed as mandates for practice 
     guidelines, coverage recommendations, payment, or policy 
     recommendations; and
       ``(v) not include any data which would violate the privacy 
     of research participants or any confidentiality agreements 
     made with respect to the use of data under this section.
       ``(B) Definition of research findings.--In this paragraph, 
     the term `research findings' means the results of a study or 
     assessment.
       ``(9) Adoption.--Subject to subsection (h)(1), the 
     Institute shall adopt the national priorities identified 
     under paragraph (1)(A), the research project agenda 
     established under paragraph (1)(B), the methodological 
     standards developed and updated by the methodology committee 
     under paragraph (6)(C)(i), and any peer-review process 
     provided under paragraph (7) by majority vote. In the case 
     where the Institute does not adopt such processes in 
     accordance with the preceding sentence, the processes shall 
     be referred to the appropriate staff or entity within the 
     Institute (or, in the case of the methodological standards, 
     the methodology committee) for further review.
       ``(10) Annual reports.--The Institute shall submit an 
     annual report to Congress and the President, and shall make 
     the annual report available to the public. Such report shall 
     contain--
       ``(A) a description of the activities conducted under this 
     section, research priorities identified under paragraph 
     (1)(A) and methodological standards developed and updated by 
     the methodology committee under paragraph (6)(C)(i) that are 
     adopted under paragraph (9) during the preceding year;
       ``(B) the research project agenda and budget of the 
     Institute for the following year;
       ``(C) any administrative activities conducted by the 
     Institute during the preceding year;
       ``(D) the names of individuals contributing to any peer-
     review process under paragraph (7), without identifying them 
     with a particular research project; and
       ``(E) any other relevant information (including information 
     on the membership of the Board, expert advisory panels, 
     methodology committee, and the executive staff of the 
     Institute, any conflicts of interest with respect to these 
     individuals, and any bylaws adopted by the Board during the 
     preceding year).
       ``(e) Administration.--
       ``(1) In general.--Subject to paragraph (2), the Board 
     shall carry out the duties of the Institute.
       ``(2) Nondelegable duties.--The activities described in 
     subsections (d)(1) and (d)(9) are nondelegable.
       ``(f) Board of Governors.--
       ``(1) In general.--The Institute shall have a Board of 
     Governors, which shall consist of the following members:
       ``(A) The Director of Agency for Healthcare Research and 
     Quality (or the Director's designee).
       ``(B) The Director of the National Institutes of Health (or 
     the Director's designee).
       ``(C) Seventeen members appointed, not later than 6 months 
     after the date of enactment of this section, by the 
     Comptroller General of the United States as follows:
       ``(i) 3 members representing patients and health care 
     consumers.
       ``(ii) 5 members representing physicians and providers, 
     including at least 1 surgeon, nurse, State-licensed 
     integrative health care practitioner, and representative of a 
     hospital.
       ``(iii) 3 members representing private payers, of whom at 
     least 1 member shall represent health insurance issuers and 
     at least 1 member shall represent employers who self-insure 
     employee benefits.
       ``(iv) 3 members representing pharmaceutical, device, and 
     diagnostic manufacturers or developers.
       ``(v) 1 member representing quality improvement or 
     independent health service researchers.
       ``(vi) 2 members representing the Federal Government or the 
     States, including at least 1 member representing a Federal 
     health program or agency.
       ``(2) Qualifications.--The Board shall represent a broad 
     range of perspectives and collectively have scientific 
     expertise in clinical health sciences research, including 
     epidemiology, decisions sciences, health economics, and 
     statistics. In appointing the Board, the Comptroller General 
     of the United States shall consider and disclose any 
     conflicts of interest in accordance with subsection 
     (h)(4)(B). Members of the Board shall be recused from 
     relevant Institute activities in the case where the member 
     (or an immediate family member of such member) has a real 
     conflict of interest directly related to the research project 
     or the matter that could affect or be affected by such 
     participation.
       ``(3) Terms; vacancies.--A member of the Board shall be 
     appointed for a term of 6 years, except with respect to the 
     members first appointed, whose terms of appointment shall be 
     staggered evenly over 2-year increments. No individual shall 
     be appointed to the Board for more than 2 terms. Vacancies 
     shall be filled in the same manner as the original 
     appointment was made.
       ``(4) Chairperson and vice-chairperson.--The Comptroller 
     General of the United States shall designate a Chairperson 
     and Vice Chairperson of the Board from among the members of 
     the Board. Such members shall serve as Chairperson or Vice 
     Chairperson for a period of 3 years.
       ``(5) Compensation.--Each member of the Board who is not an 
     officer or employee of the Federal Government shall be 
     entitled to compensation (equivalent to the rate provided for 
     level IV of the Executive Schedule under section 5315 of 
     title 5, United States Code) and expenses incurred while 
     performing the duties of the Board. An officer or employee of 
     the Federal government who is a member of the Board shall be 
     exempt from compensation.
       ``(6) Director and staff; experts and consultants.--The 
     Board may employ and fix the compensation of an Executive 
     Director and such other personnel as may be necessary to 
     carry out the duties of the Institute and may seek such 
     assistance and support of, or contract with, experts and 
     consultants that may be necessary for the performance of the 
     duties of the Institute.
       ``(7) Meetings and hearings.--The Board shall meet and hold 
     hearings at the call of the Chairperson or a majority of its 
     members. Meetings not solely concerning matters of personnel 
     shall be advertised at least 7 days in advance and open to 
     the public. A majority of the Board members shall constitute 
     a quorum, but a lesser number of members may meet and hold 
     hearings.
       ``(g) Financial and Governmental Oversight.--
       ``(1) Contract for audit.--The Institute shall provide for 
     the conduct of financial audits of the Institute on an annual 
     basis by a private entity with expertise in conducting 
     financial audits.
       ``(2) Review and annual reports.--
       ``(A) Review.--The Comptroller General of the United States 
     shall review the following:
       ``(i) Not less frequently than on an annual basis, the 
     financial audits conducted under paragraph (1).
       ``(ii) Not less frequently than every 5 years, the 
     processes established by the Institute, including the 
     research priorities and the conduct of research projects, in 
     order to determine whether information produced by such 
     research projects is objective and credible, is produced in a 
     manner consistent with the requirements under this section, 
     and is developed through a transparent process.
       ``(iii) Not less frequently than every 5 years, the 
     dissemination and training activities and data networks 
     established under section 937 of the Public Health Service 
     Act, including the methods and products used to disseminate 
     research, the types of training conducted and supported, and 
     the types and functions of the data networks established, in 
     order to determine whether the activities and data are 
     produced in a manner consistent with the requirements under 
     such section.

[[Page 4368]]

       ``(iv) Not less frequently than every 5 years, the overall 
     effectiveness of activities conducted under this section and 
     the dissemination, training, and capacity building activities 
     conducted under section 937 of the Public Health Service Act. 
     Such review shall include an analysis of the extent to which 
     research findings are used by health care decision-makers, 
     the effect of the dissemination of such findings on reducing 
     practice variation and disparities in health care, and the 
     effect of the research conducted and disseminated on 
     innovation and the health care economy of the United States.
       ``(v) Not later than 8 years after the date of enactment of 
     this section, the adequacy and use of the funding for the 
     Institute and the activities conducted under section 937 of 
     the Public Health Service Act, including a determination as 
     to whether, based on the utilization of research findings by 
     public and private payers, funding sources for the Patient-
     Centered Outcomes Research Trust Fund under section 9511 of 
     the Internal Revenue Code of 1986 are appropriate and whether 
     such sources of funding should be continued or adjusted.
       ``(B) Annual reports.--Not later than April 1 of each year, 
     the Comptroller General of the United States shall submit to 
     Congress a report containing the results of the review 
     conducted under subparagraph (A) with respect to the 
     preceding year (or years, if applicable), together with 
     recommendations for such legislation and administrative 
     action as the Comptroller General determines appropriate.
       ``(h) Ensuring Transparency, Credibility, and Access.--The 
     Institute shall establish procedures to ensure that the 
     following requirements for ensuring transparency, 
     credibility, and access are met:
       ``(1) Public comment periods.--The Institute shall provide 
     for a public comment period of not less than 45 days and not 
     more than 60 days prior to the adoption under subsection 
     (d)(9) of the national priorities identified under subsection 
     (d)(1)(A), the research project agenda established under 
     subsection (d)(1)(B), the methodological standards developed 
     and updated by the methodology committee under subsection 
     (d)(6)(C)(i), and the peer-review process provided under 
     paragraph (7), and after the release of draft findings with 
     respect to systematic reviews of existing research and 
     evidence.
       ``(2) Additional forums.--The Institute shall support 
     forums to increase public awareness and obtain and 
     incorporate public input and feedback through media (such as 
     an Internet website) on research priorities, research 
     findings, and other duties, activities, or processes the 
     Institute determines appropriate.
       ``(3) Public availability.--The Institute shall make 
     available to the public and disclose through the official 
     public Internet website of the Institute the following:
       ``(A) Information contained in research findings as 
     specified in subsection (d)(9).
       ``(B) The process and methods for the conduct of research, 
     including the identity of the entity and the investigators 
     conducing such research and any conflicts of interests of 
     such parties, any direct or indirect links the entity has to 
     industry, and research protocols, including measures taken, 
     methods of research and analysis, research results, and such 
     other information the Institute determines appropriate) 
     concurrent with the release of research findings.
       ``(C) Notice of public comment periods under paragraph (1), 
     including deadlines for public comments.
       ``(D) Subsequent comments received during each of the 
     public comment periods.
       ``(E) In accordance with applicable laws and processes and 
     as the Institute determines appropriate, proceedings of the 
     Institute.
       ``(4) Disclosure of conflicts of interest.--
       ``(A) In general.--A conflict of interest shall be 
     disclosed in the following manner:
       ``(i) By the Institute in appointing members to an expert 
     advisory panel under subsection (d)(4), in selecting 
     individuals to contribute to any peer-review process under 
     subsection (d)(7), and for employment as executive staff of 
     the Institute.
       ``(ii) By the Comptroller General in appointing members of 
     the methodology committee under subsection (d)(6);
       ``(iii) By the Institute in the annual report under 
     subsection (d)(10), except that, in the case of individuals 
     contributing to any such peer review process, such 
     description shall be in a manner such that those individuals 
     cannot be identified with a particular research project.
       ``(B) Manner of disclosure.--Conflicts of interest shall be 
     disclosed as described in subparagraph (A) as soon as 
     practicable on the Internet web site of the Institute and of 
     the Government Accountability Office. The information 
     disclosed under the preceding sentence shall include the 
     type, nature, and magnitude of the interests of the 
     individual involved, except to the extent that the individual 
     recuses himself or herself from participating in the 
     consideration of or any other activity with respect to the 
     study as to which the potential conflict exists.
       ``(i) Rules.--The Institute, its Board or staff, shall be 
     prohibited from accepting gifts, bequeaths, or donations of 
     services or property. In addition, the Institute shall be 
     prohibited from establishing a corporation or generating 
     revenues from activities other than as provided under this 
     section.
       ``(j) Rules of Construction.--
       ``(1) Coverage.--Nothing in this section shall be 
     construed--
       ``(A) to permit the Institute to mandate coverage, 
     reimbursement, or other policies for any public or private 
     payer; or
       ``(B) as preventing the Secretary from covering the routine 
     costs of clinical care received by an individual entitled to, 
     or enrolled for, benefits under title XVIII, XIX, or XXI in 
     the case where such individual is participating in a clinical 
     trial and such costs would otherwise be covered under such 
     title with respect to the beneficiary.''.
       (b) Dissemination and Building Capacity for Research.--
     Title IX of the Public Health Service Act (42 U.S.C. 299 et 
     seq.), as amended by section 3606, is further amended by 
     inserting after section 936 the following:

     ``SEC. 937. DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.

       ``(a) In General.--
       ``(1) Dissemination.--The Office of Communication and 
     Knowledge Transfer (referred to in this section as the 
     `Office') at the Agency for Healthcare Research and Quality 
     (or any other relevant office designated by Agency for 
     Healthcare Research and Quality), in consultation with the 
     National Institutes of Health, shall broadly disseminate the 
     research findings that are published by the Patient Centered 
     Outcomes Research Institute established under section 1181(b) 
     of the Social Security Act (referred to in this section as 
     the `Institute') and other government-funded research 
     relevant to comparative clinical effectiveness research. The 
     Office shall create informational tools that organize and 
     disseminate research findings for physicians, health care 
     providers, patients, payers, and policy makers. The Office 
     shall also develop a publicly available resource database 
     that collects and contains government-funded evidence and 
     research from public, private, not-for profit, and academic 
     sources.
       ``(2) Requirements.--The Office shall provide for the 
     dissemination of the Institute's research findings and 
     government-funded research relevant to comparative clinical 
     effectiveness research to physicians, health care providers, 
     patients, vendors of health information technology focused on 
     clinical decision support, appropriate professional 
     associations, and Federal and private health plans. 
     Materials, forums, and media used to disseminate the 
     findings, informational tools, and resource databases shall--
       ``(A) include a description of considerations for specific 
     subpopulations, the research methodology, and the limitations 
     of the research, and the names of the entities, agencies, 
     instrumentalities, and individuals who conducted any research 
     which was published by the Institute; and
       ``(B) not be construed as mandates, guidelines, or 
     recommendations for payment, coverage, or treatment.
       ``(b) Incorporation of Research Findings.--The Office, in 
     consultation with relevant medical and clinical associations, 
     shall assist users of health information technology focused 
     on clinical decision support to promote the timely 
     incorporation of research findings disseminated under 
     subsection (a) into clinical practices and to promote the 
     ease of use of such incorporation.
       ``(c) Feedback.--The Office shall establish a process to 
     receive feedback from physicians, health care providers, 
     patients, and vendors of health information technology 
     focused on clinical decision support, appropriate 
     professional associations, and Federal and private health 
     plans about the value of the information disseminated and the 
     assistance provided under this section.
       ``(d) Rule of Construction.--Nothing in this section shall 
     preclude the Institute from making its research findings 
     publicly available as required under section 1181(d)(8) of 
     the Social Security Act.
       ``(e) Training of Researchers.--The Agency for Health Care 
     Research and Quality, in consultation with the National 
     Institutes of Health, shall build capacity for comparative 
     clinical effectiveness research by establishing a grant 
     program that provides for the training of researchers in the 
     methods used to conduct such research, including systematic 
     reviews of existing research and primary research such as 
     clinical trials. At a minimum, such training shall be in 
     methods that meet the methodological standards adopted under 
     section 1181(d)(9) of the Social Security Act.
       ``(f) Building Data for Research.--The Secretary shall 
     provide for the coordination of relevant Federal health 
     programs to build data capacity for comparative clinical 
     effectiveness research, including the development and use of 
     clinical registries and health outcomes research data 
     networks, in order to develop and maintain a comprehensive, 
     interoperable data network to collect, link, and analyze data 
     on outcomes and effectiveness from multiple sources, 
     including electronic health records.
       ``(g) Authority To Contract With the Institute.--Agencies 
     and instrumentalities of the Federal Government may enter 
     into agreements with the Institute, and accept and retain 
     funds, for the conduct and support of research described in 
     this part, provided that the research to be conducted or 
     supported under such agreements is authorized under the 
     governing statutes of such agencies and instrumentalities.''.
       (c) In General.--Part D of title XI of the Social Security 
     Act, as added by subsection (a), is amended by adding at the 
     end the following new section:


  ``limitations on certain uses of comparative clinical effectiveness 
                                research

       ``Sec. 1182.  (a) The Secretary may only use evidence and 
     findings from research conducted under section 1181 to make a 
     determination regarding coverage under title XVIII if such 
     use is through an iterative and transparent process

[[Page 4369]]

     which includes public comment and considers the effect on 
     subpopulations.
       ``(b) Nothing in section 1181 shall be construed as--
       ``(1) superceding or modifying the coverage of items or 
     services under title XVIII that the Secretary determines are 
     reasonable and necessary under section 1862(l)(1); or
       ``(2) authorizing the Secretary to deny coverage of items 
     or services under such title solely on the basis of 
     comparative clinical effectiveness research.
       ``(c)(1) The Secretary shall not use evidence or findings 
     from comparative clinical effectiveness research conducted 
     under section 1181 in determining coverage, reimbursement, or 
     incentive programs under title XVIII in a manner that treats 
     extending the life of an elderly, disabled, or terminally ill 
     individual as of lower value than extending the life of an 
     individual who is younger, nondisabled, or not terminally 
     ill.
       ``(2) Paragraph (1) shall not be construed as preventing 
     the Secretary from using evidence or findings from such 
     comparative clinical effectiveness research in determining 
     coverage, reimbursement, or incentive programs under title 
     XVIII based upon a comparison of the difference in the 
     effectiveness of alternative treatments in extending an 
     individual's life due to the individual's age, disability, or 
     terminal illness.
       ``(d)(1) The Secretary shall not use evidence or findings 
     from comparative clinical effectiveness research conducted 
     under section 1181 in determining coverage, reimbursement, or 
     incentive programs under title XVIII in a manner that 
     precludes, or with the intent to discourage, an individual 
     from choosing a health care treatment based on how the 
     individual values the tradeoff between extending the length 
     of their life and the risk of disability.
       ``(2)(A) Paragraph (1) shall not be construed to--
       ``(i) limit the application of differential copayments 
     under title XVIII based on factors such as cost or type of 
     service; or
       ``(ii) prevent the Secretary from using evidence or 
     findings from such comparative clinical effectiveness 
     research in determining coverage, reimbursement, or incentive 
     programs under such title based upon a comparison of the 
     difference in the effectiveness of alternative health care 
     treatments in extending an individual's life due to that 
     individual's age, disability, or terminal illness.
       ``(3) Nothing in the provisions of, or amendments made by 
     the Patient Protection and Affordable Care Act, shall be 
     construed to limit comparative clinical effectiveness 
     research or any other research, evaluation, or dissemination 
     of information concerning the likelihood that a health care 
     treatment will result in disability.
       ``(e) The Patient-Centered Outcomes Research Institute 
     established under section 1181(b)(1) shall not develop or 
     employ a dollars-per-quality adjusted life year (or similar 
     measure that discounts the value of a life because of an 
     individual's disability) as a threshold to establish what 
     type of health care is cost effective or recommended. The 
     Secretary shall not utilize such an adjusted life year (or 
     such a similar measure) as a threshold to determine coverage, 
     reimbursement, or incentive programs under title XVIII.''.
       (d) In General.--Part D of title XI of the Social Security 
     Act, as added by subsection (a) and amended by subsection 
     (c), is amended by adding at the end the following new 
     section:


``trust fund transfers to patient-centered outcomes research trust fund

       ``Sec. 1183.  (a) In General.--The Secretary shall provide 
     for the transfer, from the Federal Hospital Insurance Trust 
     Fund under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841, in proportion (as 
     estimated by the Secretary) to the total expenditures during 
     such fiscal year that are made under title XVIII from the 
     respective trust fund, to the Patient-Centered Outcomes 
     Research Trust Fund (referred to in this section as the 
     `PCORTF') under section 9511 of the Internal Revenue Code of 
     1986, of the following:
       ``(1) For fiscal year 2013, an amount equal to $1 
     multiplied by the average number of individuals entitled to 
     benefits under part A, or enrolled under part B, of title 
     XVIII during such fiscal year.
       ``(2) For each of fiscal years 2014, 2015, 2016, 2017, 
     2018, and 2019, an amount equal to $2 multiplied by the 
     average number of individuals entitled to benefits under part 
     A, or enrolled under part B, of title XVIII during such 
     fiscal year.
       ``(b) Adjustments for Increases in Health Care Spending.--
     In the case of any fiscal year beginning after September 30, 
     2014, the dollar amount in effect under subsection (a)(2) for 
     such fiscal year shall be equal to the sum of such dollar 
     amount for the previous fiscal year (determined after the 
     application of this subsection), plus an amount equal to the 
     product of--
       ``(1) such dollar amount for the previous fiscal year, 
     multiplied by
       ``(2) the percentage increase in the projected per capita 
     amount of National Health Expenditures, as most recently 
     published by the Secretary before the beginning of the fiscal 
     year.''.
       (e) Patient-Centered Outcomes Research Trust Fund; 
     Financing for Trust Fund.--
       (1) Establishment of trust fund.--
       (A) In general.--Subchapter A of chapter 98 of the Internal 
     Revenue Code of 1986 (relating to establishment of trust 
     funds) is amended by adding at the end the following new 
     section:

     ``SEC. 9511. PATIENT-CENTERED OUTCOMES RESEARCH TRUST FUND.

       ``(a) Creation of Trust Fund.--There is established in the 
     Treasury of the United States a trust fund to be known as the 
     `Patient-Centered Outcomes Research Trust Fund' (hereafter in 
     this section referred to as the `PCORTF'), consisting of such 
     amounts as may be appropriated or credited to such Trust Fund 
     as provided in this section and section 9602(b).
       ``(b) Transfers to Fund.--
       ``(1) Appropriation.--There are hereby appropriated to the 
     Trust Fund the following:
       ``(A) For fiscal year 2010, $10,000,000.
       ``(B) For fiscal year 2011, $50,000,000.
       ``(C) For fiscal year 2012, $150,000,000.
       ``(D) For fiscal year 2013--
       ``(i) an amount equivalent to the net revenues received in 
     the Treasury from the fees imposed under subchapter B of 
     chapter 34 (relating to fees on health insurance and self-
     insured plans) for such fiscal year; and
       ``(ii) $150,000,000.
       ``(E) For each of fiscal years 2014, 2015, 2016, 2017, 
     2018, and 2019--
       ``(i) an amount equivalent to the net revenues received in 
     the Treasury from the fees imposed under subchapter B of 
     chapter 34 (relating to fees on health insurance and self-
     insured plans) for such fiscal year; and
       ``(ii) $150,000,000.
     The amounts appropriated under subparagraphs (A), (B), (C), 
     (D)(ii), and (E)(ii) shall be transferred from the general 
     fund of the Treasury, from funds not otherwise appropriated.
       ``(2) Trust fund transfers.--In addition to the amounts 
     appropriated under paragraph (1), there shall be credited to 
     the PCORTF the amounts transferred under section 1183 of the 
     Social Security Act.
       ``(3) Limitation on transfers to pcortf.--No amount may be 
     appropriated or transferred to the PCORTF on and after the 
     date of any expenditure from the PCORTF which is not an 
     expenditure permitted under this section. The determination 
     of whether an expenditure is so permitted shall be made 
     without regard to--
       ``(A) any provision of law which is not contained or 
     referenced in this chapter or in a revenue Act, and
       ``(B) whether such provision of law is a subsequently 
     enacted provision or directly or indirectly seeks to waive 
     the application of this paragraph.
       ``(c) Trustee.--The Secretary of the Treasury shall be a 
     trustee of the PCORTF.
       ``(d) Expenditures From Fund.--
       ``(1) Amounts available to the patient-centered outcomes 
     research institute.--Subject to paragraph (2), amounts in the 
     PCORTF are available, without further appropriation, to the 
     Patient-Centered Outcomes Research Institute established 
     under section 1181(b) of the Social Security Act for carrying 
     out part D of title XI of the Social Security Act (as in 
     effect on the date of enactment of such Act).
       ``(2) Transfer of funds.--
       ``(A) In general.--The trustee of the PCORTF shall provide 
     for the transfer from the PCORTF of 20 percent of the amounts 
     appropriated or credited to the PCORTF for each of fiscal 
     years 2011 through 2019 to the Secretary of Health and Human 
     Services to carry out section 937 of the Public Health 
     Service Act.
       ``(B) Availability.--Amounts transferred under subparagraph 
     (A) shall remain available until expended.
       ``(C) Requirements.--Of the amounts transferred under 
     subparagraph (A) with respect to a fiscal year, the Secretary 
     of Health and Human Services shall distribute--
       ``(i) 80 percent to the Office of Communication and 
     Knowledge Transfer of the Agency for Healthcare Research and 
     Quality (or any other relevant office designated by Agency 
     for Healthcare Research and Quality) to carry out the 
     activities described in section 937 of the Public Health 
     Service Act; and
       ``(ii) 20 percent to the Secretary to carry out the 
     activities described in such section 937.
       ``(e) Net Revenues.--For purposes of this section, the term 
     `net revenues' means the amount estimated by the Secretary of 
     the Treasury based on the excess of--
       ``(1) the fees received in the Treasury under subchapter B 
     of chapter 34, over
       ``(2) the decrease in the tax imposed by chapter 1 
     resulting from the fees imposed by such subchapter.
       ``(f) Termination.--No amounts shall be available for 
     expenditure from the PCORTF after September 30, 2019, and any 
     amounts in such Trust Fund after such date shall be 
     transferred to the general fund of the Treasury.''.
       (B) Clerical amendment.--The table of sections for 
     subchapter A of chapter 98 of such Code is amended by adding 
     at the end the following new item:

``Sec. 9511. Patient-centered outcomes research trust fund.''.

       (2) Financing for fund from fees on insured and self-
     insured health plans.--
       (A) General rule.--Chapter 34 of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subchapter:

         ``Subchapter B--Insured and Self-Insured Health Plans

``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.

     ``SEC. 4375. HEALTH INSURANCE.

       ``(a) Imposition of Fee.--There is hereby imposed on each 
     specified health insurance policy for each policy year ending 
     after September 30, 2012, a fee equal to the product of $2 
     ($1 in the case of policy years ending during fiscal year 
     2013) multiplied by the average number of lives covered under 
     the policy.

[[Page 4370]]

       ``(b) Liability for Fee.--The fee imposed by subsection (a) 
     shall be paid by the issuer of the policy.
       ``(c) Specified Health Insurance Policy.--For purposes of 
     this section:
       ``(1) In general.--Except as otherwise provided in this 
     section, the term `specified health insurance policy' means 
     any accident or health insurance policy (including a policy 
     under a group health plan) issued with respect to individuals 
     residing in the United States.
       ``(2) Exemption for certain policies.--The term `specified 
     health insurance policy' does not include any insurance if 
     substantially all of its coverage is of excepted benefits 
     described in section 9832(c).
       ``(3) Treatment of prepaid health coverage arrangements.--
       ``(A) In general.--In the case of any arrangement described 
     in subparagraph (B), such arrangement shall be treated as a 
     specified health insurance policy, and the person referred to 
     in such subparagraph shall be treated as the issuer.
       ``(B) Description of arrangements.--An arrangement is 
     described in this subparagraph if under such arrangement 
     fixed payments or premiums are received as consideration for 
     any person's agreement to provide or arrange for the 
     provision of accident or health coverage to residents of the 
     United States, regardless of how such coverage is provided or 
     arranged to be provided.
       ``(d) Adjustments for Increases in Health Care Spending.--
     In the case of any policy year ending in any fiscal year 
     beginning after September 30, 2014, the dollar amount in 
     effect under subsection (a) for such policy year shall be 
     equal to the sum of such dollar amount for policy years 
     ending in the previous fiscal year (determined after the 
     application of this subsection), plus an amount equal to the 
     product of--
       ``(1) such dollar amount for policy years ending in the 
     previous fiscal year, multiplied by
       ``(2) the percentage increase in the projected per capita 
     amount of National Health Expenditures, as most recently 
     published by the Secretary before the beginning of the fiscal 
     year.
       ``(e) Termination.--This section shall not apply to policy 
     years ending after September 30, 2019.

     ``SEC. 4376. SELF-INSURED HEALTH PLANS.

       ``(a) Imposition of Fee.--In the case of any applicable 
     self-insured health plan for each plan year ending after 
     September 30, 2012, there is hereby imposed a fee equal to $2 
     ($1 in the case of plan years ending during fiscal year 2013) 
     multiplied by the average number of lives covered under the 
     plan.
       ``(b) Liability for Fee.--
       ``(1) In general.--The fee imposed by subsection (a) shall 
     be paid by the plan sponsor.
       ``(2) Plan sponsor.--For purposes of paragraph (1) the term 
     `plan sponsor' means--
       ``(A) the employer in the case of a plan established or 
     maintained by a single employer,
       ``(B) the employee organization in the case of a plan 
     established or maintained by an employee organization,
       ``(C) in the case of--
       ``(i) a plan established or maintained by 2 or more 
     employers or jointly by 1 or more employers and 1 or more 
     employee organizations,
       ``(ii) a multiple employer welfare arrangement, or
       ``(iii) a voluntary employees' beneficiary association 
     described in section 501(c)(9), the association, committee, 
     joint board of trustees, or other similar group of 
     representatives of the parties who establish or maintain the 
     plan, or
       ``(D) the cooperative or association described in 
     subsection (c)(2)(F) in the case of a plan established or 
     maintained by such a cooperative or association.
       ``(c) Applicable Self-insured Health Plan.--For purposes of 
     this section, the term `applicable self-insured health plan' 
     means any plan for providing accident or health coverage if--
       ``(1) any portion of such coverage is provided other than 
     through an insurance policy, and
       ``(2) such plan is established or maintained--
       ``(A) by 1 or more employers for the benefit of their 
     employees or former employees,
       ``(B) by 1 or more employee organizations for the benefit 
     of their members or former members,
       ``(C) jointly by 1 or more employers and 1 or more employee 
     organizations for the benefit of employees or former 
     employees,
       ``(D) by a voluntary employees' beneficiary association 
     described in section 501(c)(9),
       ``(E) by any organization described in section 501(c)(6), 
     or
       ``(F) in the case of a plan not described in the preceding 
     subparagraphs, by a multiple employer welfare arrangement (as 
     defined in section 3(40) of Employee Retirement Income 
     Security Act of 1974), a rural electric cooperative (as 
     defined in section 3(40)(B)(iv) of such Act), or a rural 
     telephone cooperative association (as defined in section 
     3(40)(B)(v) of such Act).
       ``(d) Adjustments for Increases in Health Care Spending.--
     In the case of any plan year ending in any fiscal year 
     beginning after September 30, 2014, the dollar amount in 
     effect under subsection (a) for such plan year shall be equal 
     to the sum of such dollar amount for plan years ending in the 
     previous fiscal year (determined after the application of 
     this subsection), plus an amount equal to the product of--
       ``(1) such dollar amount for plan years ending in the 
     previous fiscal year, multiplied by
       ``(2) the percentage increase in the projected per capita 
     amount of National Health Expenditures, as most recently 
     published by the Secretary before the beginning of the fiscal 
     year.
       ``(e) Termination.--This section shall not apply to plan 
     years ending after September 30, 2019.

     ``SEC. 4377. DEFINITIONS AND SPECIAL RULES.

       ``(a) Definitions.--For purposes of this subchapter--
       ``(1) Accident and health coverage.--The term `accident and 
     health coverage' means any coverage which, if provided by an 
     insurance policy, would cause such policy to be a specified 
     health insurance policy (as defined in section 4375(c)).
       ``(2) Insurance policy.--The term `insurance policy' means 
     any policy or other instrument whereby a contract of 
     insurance is issued, renewed, or extended.
       ``(3) United states.--The term `United States' includes any 
     possession of the United States.
       ``(b) Treatment of Governmental Entities.--
       ``(1) In general.--For purposes of this subchapter--
       ``(A) the term `person' includes any governmental entity, 
     and
       ``(B) notwithstanding any other law or rule of law, 
     governmental entities shall not be exempt from the fees 
     imposed by this subchapter except as provided in paragraph 
     (2).
       ``(2) Treatment of exempt governmental programs.--In the 
     case of an exempt governmental program, no fee shall be 
     imposed under section 4375 or section 4376 on any covered 
     life under such program.
       ``(3) Exempt governmental program defined.--For purposes of 
     this subchapter, the term `exempt governmental program' 
     means--
       ``(A) any insurance program established under title XVIII 
     of the Social Security Act,
       ``(B) the medical assistance program established by title 
     XIX or XXI of the Social Security Act,
       ``(C) any program established by Federal law for providing 
     medical care (other than through insurance policies) to 
     individuals (or the spouses and dependents thereof) by reason 
     of such individuals being members of the Armed Forces of the 
     United States or veterans, and
       ``(D) any program established by Federal law for providing 
     medical care (other than through insurance policies) to 
     members of Indian tribes (as defined in section 4(d) of the 
     Indian Health Care Improvement Act).
       ``(c) Treatment as Tax.--For purposes of subtitle F, the 
     fees imposed by this subchapter shall be treated as if they 
     were taxes.
       ``(d) No Cover Over to Possessions.--Notwithstanding any 
     other provision of law, no amount collected under this 
     subchapter shall be covered over to any possession of the 
     United States.''.
       (B) Clerical amendments.--
       (i) Chapter 34 of such Code is amended by striking the 
     chapter heading and inserting the following:

           ``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES

          ``subchapter a. policies issued by foreign insurers

         ``subchapter b. insured and self-insured health plans

         ``Subchapter A--Policies Issued By Foreign Insurers''.

       (ii) The table of chapters for subtitle D of such Code is 
     amended by striking the item relating to chapter 34 and 
     inserting the following new item:

          ``Chapter 34--Taxes on Certain Insurance Policies''.

       (f) Tax-exempt Status of the Patient-centered Outcomes 
     Research Institute.--Subsection 501(l) of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new paragraph:
       ``(4) The Patient-Centered Outcomes Research Institute 
     established under section 1181(b) of the Social Security 
     Act.''.

     SEC. 6302. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE 
                   EFFECTIVENESS RESEARCH.

       Notwithstanding any other provision of law, the Federal 
     Coordinating Council for Comparative Effectiveness Research 
     established under section 804 of Division A of the American 
     Recovery and Reinvestment Act of 2009 (42 U.S.C. 299b-8), 
     including the requirement under subsection (e)(2) of such 
     section, shall terminate on the date of enactment of this 
     Act.

 Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions

     SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT 
                   REQUIREMENTS UNDER MEDICARE, MEDICAID, AND 
                   CHIP.

       (a) Medicare.--Section 1866(j) of the Social Security Act 
     (42 U.S.C. 1395cc(j)) is amended--
       (1) in paragraph (1)(A), by adding at the end the 
     following: ``Such process shall include screening of 
     providers and suppliers in accordance with paragraph (2), a 
     provisional period of enhanced oversight in accordance with 
     paragraph (3), disclosure requirements in accordance with 
     paragraph (4), the imposition of temporary enrollment 
     moratoria in accordance with paragraph (5), and the 
     establishment of compliance programs in accordance with 
     paragraph (6).'';
       (2) by redesignating paragraph (2) as paragraph (7); and
       (3) by inserting after paragraph (1) the following:
       ``(2) Provider screening.--
       ``(A) Procedures.--Not later than 180 days after the date 
     of enactment of this paragraph, the Secretary, in 
     consultation with the Inspector General of the Department of 
     Health and Human Services, shall establish procedures under 
     which screening is conducted with respect to providers of 
     medical or other items or services

[[Page 4371]]

     and suppliers under the program under this title, the 
     Medicaid program under title XIX, and the CHIP program under 
     title XXI.
       ``(B) Level of screening.--The Secretary shall determine 
     the level of screening conducted under this paragraph 
     according to the risk of fraud, waste, and abuse, as 
     determined by the Secretary, with respect to the category of 
     provider of medical or other items or services or supplier. 
     Such screening--
       ``(i) shall include a licensure check, which may include 
     such checks across States; and
       ``(ii) may, as the Secretary determines appropriate based 
     on the risk of fraud, waste, and abuse described in the 
     preceding sentence, include--

       ``(I) a criminal background check;
       ``(II) fingerprinting;
       ``(III) unscheduled and unannounced site visits, including 
     preenrollment site visits;
       ``(IV) database checks (including such checks across 
     States); and
       ``(V) such other screening as the Secretary determines 
     appropriate.

       ``(C) Application fees.--
       ``(i) Individual providers.--Except as provided in clause 
     (iii), the Secretary shall impose a fee on each individual 
     provider of medical or other items or services or supplier 
     (such as a physician, physician assistant, nurse 
     practitioner, or clinical nurse specialist) with respect to 
     which screening is conducted under this paragraph in an 
     amount equal to--

       ``(I) for 2010, $200; and
       ``(II) for 2011 and each subsequent year, the amount 
     determined under this clause for the preceding year, adjusted 
     by the percentage change in the consumer price index for all 
     urban consumers (all items; United States city average) for 
     the 12-month period ending with June of the previous year.

       ``(ii) Institutional providers.--Except as provided in 
     clause (iii), the Secretary shall impose a fee on each 
     institutional provider of medical or other items or services 
     or supplier (such as a hospital or skilled nursing facility) 
     with respect to which screening is conducted under this 
     paragraph in an amount equal to--

       ``(I) for 2010, $500; and
       ``(II) for 2011 and each subsequent year, the amount 
     determined under this clause for the preceding year, adjusted 
     by the percentage change in the consumer price index for all 
     urban consumers (all items; United States city average) for 
     the 12-month period ending with June of the previous year.

       ``(iii) Hardship exception; waiver for certain medicaid 
     providers.--The Secretary may, on a case-by-case basis, 
     exempt a provider of medical or other items or services or 
     supplier from the imposition of an application fee under this 
     subparagraph if the Secretary determines that the imposition 
     of the application fee would result in a hardship. The 
     Secretary may waive the application fee under this 
     subparagraph for providers enrolled in a State Medicaid 
     program for whom the State demonstrates that imposition of 
     the fee would impede beneficiary access to care.
       ``(iv) Use of funds.--Amounts collected as a result of the 
     imposition of a fee under this subparagraph shall be used by 
     the Secretary for program integrity efforts, including to 
     cover the costs of conducting screening under this paragraph 
     and to carry out this subsection and section 1128J.
       ``(D) Application and enforcement.--
       ``(i) New providers of services and suppliers.--The 
     screening under this paragraph shall apply, in the case of a 
     provider of medical or other items or services or supplier 
     who is not enrolled in the program under this title, title 
     XIX , or title XXI as of the date of enactment of this 
     paragraph, on or after the date that is 1 year after such 
     date of enactment.
       ``(ii) Current providers of services and suppliers.--The 
     screening under this paragraph shall apply, in the case of a 
     provider of medical or other items or services or supplier 
     who is enrolled in the program under this title, title XIX, 
     or title XXI as of such date of enactment, on or after the 
     date that is 2 years after such date of enactment.
       ``(iii) Revalidation of enrollment.--Effective beginning on 
     the date that is 180 days after such date of enactment, the 
     screening under this paragraph shall apply with respect to 
     the revalidation of enrollment of a provider of medical or 
     other items or services or supplier in the program under this 
     title, title XIX, or title XXI.
       ``(iv) Limitation on enrollment and revalidation of 
     enrollment.--In no case may a provider of medical or other 
     items or services or supplier who has not been screened under 
     this paragraph be initially enrolled or reenrolled in the 
     program under this title, title XIX, or title XXI on or after 
     the date that is 3 years after such date of enactment.
       ``(E) Expedited rulemaking.--The Secretary may promulgate 
     an interim final rule to carry out this paragraph.
       ``(3) Provisional period of enhanced oversight for new 
     providers of services and suppliers.--
       ``(A) In general.--The Secretary shall establish procedures 
     to provide for a provisional period of not less than 30 days 
     and not more than 1 year during which new providers of 
     medical or other items or services and suppliers, as the 
     Secretary determines appropriate, including categories of 
     providers or suppliers, would be subject to enhanced 
     oversight, such as prepayment review and payment caps, under 
     the program under this title, the Medicaid program under 
     title XIX. and the CHIP program under title XXI.
       ``(B) Implementation.--The Secretary may establish by 
     program instruction or otherwise the procedures under this 
     paragraph.
       ``(4) Increased disclosure requirements.--
       ``(A) Disclosure.--A provider of medical or other items or 
     services or supplier who submits an application for 
     enrollment or revalidation of enrollment in the program under 
     this title, title XIX, or title XXI on or after the date that 
     is 1 year after the date of enactment of this paragraph shall 
     disclose (in a form and manner and at such time as determined 
     by the Secretary) any current or previous affiliation 
     (directly or indirectly) with a provider of medical or other 
     items or services or supplier that has uncollected debt, has 
     been or is subject to a payment suspension under a Federal 
     health care program (as defined in section 1128B(f)), has 
     been excluded from participation under the program under this 
     title, the Medicaid program under title XIX, or the CHIP 
     program under title XXI, or has had its billing privileges 
     denied or revoked.
       ``(B) Authority to deny enrollment.--If the Secretary 
     determines that such previous affiliation poses an undue risk 
     of fraud, waste, or abuse, the Secretary may deny such 
     application. Such a denial shall be subject to appeal in 
     accordance with paragraph (7).
       ``(5) Authority to adjust payments of providers of services 
     and suppliers with the same tax identification number for 
     past-due obligations.--
       ``(A) In general.--Notwithstanding any other provision of 
     this title, in the case of an applicable provider of services 
     or supplier, the Secretary may make any necessary adjustments 
     to payments to the applicable provider of services or 
     supplier under the program under this title in order to 
     satisfy any past-due obligations described in subparagraph 
     (B)(ii) of an obligated provider of services or supplier.
       ``(B) Definitions.--In this paragraph:
       ``(i) In general.--The term `applicable provider of 
     services or supplier' means a provider of services or 
     supplier that has the same taxpayer identification number 
     assigned under section 6109 of the Internal Revenue Code of 
     1986 as is assigned to the obligated provider of services or 
     supplier under such section, regardless of whether the 
     applicable provider of services or supplier is assigned a 
     different billing number or national provider identification 
     number under the program under this title than is assigned to 
     the obligated provider of services or supplier.
       ``(ii) Obligated provider of services or supplier.--The 
     term `obligated provider of services or supplier' means a 
     provider of services or supplier that owes a past-due 
     obligation under the program under this title (as determined 
     by the Secretary).
       ``(6) Temporary moratorium on enrollment of new 
     providers.--
       ``(A) In general.--The Secretary may impose a temporary 
     moratorium on the enrollment of new providers of services and 
     suppliers, including categories of providers of services and 
     suppliers, in the program under this title, under the 
     Medicaid program under title XIX, or under the CHIP program 
     under title XXI if the Secretary determines such moratorium 
     is necessary to prevent or combat fraud, waste, or abuse 
     under either such program.
       ``(B) Limitation on review.--There shall be no judicial 
     review under section 1869, section 1878, or otherwise, of a 
     temporary moratorium imposed under subparagraph (A).
       ``(7) Compliance programs.--
       ``(A) In general.--On or after the date of implementation 
     determined by the Secretary under subparagraph (C), a 
     provider of medical or other items or services or supplier 
     within a particular industry sector or category shall, as a 
     condition of enrollment in the program under this title, 
     title XIX, or title XXI, establish a compliance program that 
     contains the core elements established under subparagraph (B) 
     with respect to that provider or supplier and industry or 
     category.
       ``(B) Establishment of core elements.--The Secretary, in 
     consultation with the Inspector General of the Department of 
     Health and Human Services, shall establish core elements for 
     a compliance program under subparagraph (A) for providers or 
     suppliers within a particular industry or category.
       ``(C) Timeline for implementation.--The Secretary shall 
     determine the timeline for the establishment of the core 
     elements under subparagraph (B) and the date of the 
     implementation of subparagraph (A) for providers or suppliers 
     within a particular industry or category. The Secretary 
     shall, in determining such date of implementation, consider 
     the extent to which the adoption of compliance programs by a 
     provider of medical or other items or services or supplier is 
     widespread in a particular industry sector or with respect to 
     a particular provider or supplier category.''.
       (b) Medicaid.--
       (1) State plan amendment.--Section 1902(a) of the Social 
     Security Act (42 U.S.C. 1396a(a)), as amended by section 
     4302(b), is amended--
       (A) in subsection (a)--
       (i) by striking ``and'' at the end of paragraph (75);
       (ii) by striking the period at the end of paragraph (76) 
     and inserting a semicolon; and
       (iii) by inserting after paragraph (76) the following:
       ``(77) provide that the State shall comply with provider 
     and supplier screening, oversight, and reporting requirements 
     in accordance with subsection (ii);''; and
       (B) by adding at the end the following:
       ``(ii) Provider and Supplier Screening, Oversight, and 
     Reporting Requirements.--

[[Page 4372]]

     For purposes of subsection (a)(77), the requirements of this 
     subsection are the following:
       ``(1) Screening.--The State complies with the process for 
     screening providers and suppliers under this title, as 
     established by the Secretary under section 1886(j)(2).
       ``(2) Provisional period of enhanced oversight for new 
     providers and suppliers.--The State complies with procedures 
     to provide for a provisional period of enhanced oversight for 
     new providers and suppliers under this title, as established 
     by the Secretary under section 1886(j)(3).
       ``(3) Disclosure requirements.--The State requires 
     providers and suppliers under the State plan or under a 
     waiver of the plan to comply with the disclosure requirements 
     established by the Secretary under section 1886(j)(4).
       ``(4) Temporary moratorium on enrollment of new providers 
     or suppliers.--
       ``(A) Temporary moratorium imposed by the secretary.--
       ``(i) In general.--Subject to clause (ii), the State 
     complies with any temporary moratorium on the enrollment of 
     new providers or suppliers imposed by the Secretary under 
     section 1886(j)(6).
       ``(ii) Exception.--A State shall not be required to comply 
     with a temporary moratorium described in clause (i) if the 
     State determines that the imposition of such temporary 
     moratorium would adversely impact beneficiaries' access to 
     medical assistance.
       ``(B) Moratorium on enrollment of providers and 
     suppliers.--At the option of the State, the State imposes, 
     for purposes of entering into participation agreements with 
     providers or suppliers under the State plan or under a waiver 
     of the plan, periods of enrollment moratoria, or numerical 
     caps or other limits, for providers or suppliers identified 
     by the Secretary as being at high-risk for fraud, waste, or 
     abuse as necessary to combat fraud, waste, or abuse, but only 
     if the State determines that the imposition of any such 
     period, cap, or other limits would not adversely impact 
     beneficiaries' access to medical assistance.
       ``(5) Compliance programs.--The State requires providers 
     and suppliers under the State plan or under a waiver of the 
     plan to establish, in accordance with the requirements of 
     section 1866(j)(7), a compliance program that contains the 
     core elements established under subparagraph (B) of that 
     section 1866(j)(7) for providers or suppliers within a 
     particular industry or category.
       ``(6) Reporting of adverse provider actions.--The State 
     complies with the national system for reporting criminal and 
     civil convictions, sanctions, negative licensure actions, and 
     other adverse provider actions to the Secretary, through the 
     Administrator of the Centers for Medicare & Medicaid 
     Services, in accordance with regulations of the Secretary.
       ``(7) Enrollment and npi of ordering or referring 
     providers.--The State requires--
       ``(A) all ordering or referring physicians or other 
     professionals to be enrolled under the State plan or under a 
     waiver of the plan as a participating provider; and
       ``(B) the national provider identifier of any ordering or 
     referring physician or other professional to be specified on 
     any claim for payment that is based on an order or referral 
     of the physician or other professional.
       ``(8) Other state oversight.--Nothing in this subsection 
     shall be interpreted to preclude or limit the ability of a 
     State to engage in provider and supplier screening or 
     enhanced provider and supplier oversight activities beyond 
     those required by the Secretary.''.
       (2) Disclosure of medicare terminated providers and 
     suppliers to states.--The Administrator of the Centers for 
     Medicare & Medicaid Services shall establish a process for 
     making available to the each State agency with responsibility 
     for administering a State Medicaid plan (or a waiver of such 
     plan) under title XIX of the Social Security Act or a child 
     health plan under title XXI the name, national provider 
     identifier, and other identifying information for any 
     provider of medical or other items or services or supplier 
     under the Medicare program under title XVIII or under the 
     CHIP program under title XXI that is terminated from 
     participation under that program within 30 days of the 
     termination (and, with respect to all such providers or 
     suppliers who are terminated from the Medicare program on the 
     date of enactment of this Act, within 90 days of such date).
       (3) Conforming amendment.--Section 1902(a)(23) of the 
     Social Security Act (42 U.S.C. 1396a), is amended by 
     inserting before the semicolon at the end the following: ``or 
     by a provider or supplier to which a moratorium under 
     subsection (ii)(4) is applied during the period of such 
     moratorium''.
       (c) CHIP.--Section 2107(e)(1) of the Social Security Act 
     (42 U.S.C. 1397gg(e)(1)), as amended by section 2101(d), is 
     amended--
       (1) by redesignating subparagraphs (D) through (M) as 
     subparagraphs (E) through (N), respectively; and
       (2) by inserting after subparagraph (C), the following:
       ``(D) Subsections (a)(77) and (ii) of section 1902 
     (relating to provider and supplier screening, oversight, and 
     reporting requirements).''.

     SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY 
                   PROVISIONS.

       (a) In General.--Part A of title XI of the Social Security 
     Act (42 U.S.C. 1301 et seq.), as amended by sections 6002, 
     6004, and 6102, is amended by inserting after section 1128I 
     the following new section:

     ``SEC. 1128J. MEDICARE AND MEDICAID PROGRAM INTEGRITY 
                   PROVISIONS.

       ``(a) Data Matching.--
       ``(1) Integrated data repository.--
       ``(A) Inclusion of certain data.--
       ``(i) In general.--The Integrated Data Repository of the 
     Centers for Medicare & Medicaid Services shall include, at a 
     minimum, claims and payment data from the following:

       ``(I) The programs under titles XVIII and XIX (including 
     parts A, B, C, and D of title XVIII).
       ``(II) The program under title XXI.
       ``(III) Health-related programs administered by the 
     Secretary of Veterans Affairs.
       ``(IV) Health-related programs administered by the 
     Secretary of Defense.
       ``(V) The program of old-age, survivors, and disability 
     insurance benefits established under title II.
       ``(VI) The Indian Health Service and the Contract Health 
     Service program.

       ``(ii) Priority for inclusion of certain data.--Inclusion 
     of the data described in subclause (I) of such clause in the 
     Integrated Data Repository shall be a priority. Data 
     described in subclauses (II) through (VI) of such clause 
     shall be included in the Integrated Data Repository as 
     appropriate.
       ``(B) Data sharing and matching.--
       ``(i) In general.--The Secretary shall enter into 
     agreements with the individuals described in clause (ii) 
     under which such individuals share and match data in the 
     system of records of the respective agencies of such 
     individuals with data in the system of records of the 
     Department of Health and Human Services for the purpose of 
     identifying potential fraud, waste, and abuse under the 
     programs under titles XVIII and XIX.
       ``(ii) Individuals described.--The following individuals 
     are described in this clause:

       ``(I) The Commissioner of Social Security.
       ``(II) The Secretary of Veterans Affairs.
       ``(III) The Secretary of Defense.
       ``(IV) The Director of the Indian Health Service.

       ``(iii) Definition of system of records.--For purposes of 
     this paragraph, the term `system of records' has the meaning 
     given such term in section 552a(a)(5) of title 5, United 
     States Code.
       ``(2) Access to claims and payment databases.--For purposes 
     of conducting law enforcement and oversight activities and to 
     the extent consistent with applicable information, privacy, 
     security, and disclosure laws, including the regulations 
     promulgated under the Health Insurance Portability and 
     Accountability Act of 1996 and section 552a of title 5, 
     United States Code, and subject to any information systems 
     security requirements under such laws or otherwise required 
     by the Secretary, the Inspector General of the Department of 
     Health and Human Services and the Attorney General shall have 
     access to claims and payment data of the Department of Health 
     and Human Services and its contractors related to titles 
     XVIII, XIX, and XXI.
       ``(b) OIG Authority To Obtain Information.--
       ``(1) In general.--Notwithstanding and in addition to any 
     other provision of law, the Inspector General of the 
     Department of Health and Human Services may, for purposes of 
     protecting the integrity of the programs under titles XVIII 
     and XIX, obtain information from any individual (including a 
     beneficiary provided all applicable privacy protections are 
     followed) or entity that--
       ``(A) is a provider of medical or other items or services, 
     supplier, grant recipient, contractor, or subcontractor; or
       ``(B) directly or indirectly provides, orders, 
     manufactures, distributes, arranges for, prescribes, 
     supplies, or receives medical or other items or services 
     payable by any Federal health care program (as defined in 
     section 1128B(f)) regardless of how the item or service is 
     paid for, or to whom such payment is made.
       ``(2) Inclusion of certain information.--Information which 
     the Inspector General may obtain under paragraph (1) includes 
     any supporting documentation necessary to validate claims for 
     payment or payments under title XVIII or XIX, including a 
     prescribing physician's medical records for an individual who 
     is prescribed an item or service which is covered under part 
     B of title XVIII, a covered part D drug (as defined in 
     section 1860D-2(e)) for which payment is made under an MA-PD 
     plan under part C of such title, or a prescription drug plan 
     under part D of such title, and any records necessary for 
     evaluation of the economy, efficiency, and effectiveness of 
     the programs under titles XVIII and XIX.
       ``(c) Administrative Remedy for Knowing Participation by 
     Beneficiary in Health Care Fraud Scheme.--
       ``(1) In general.--In addition to any other applicable 
     remedies, if an applicable individual has knowingly 
     participated in a Federal health care fraud offense or a 
     conspiracy to commit a Federal health care fraud offense, the 
     Secretary shall impose an appropriate administrative penalty 
     commensurate with the offense or conspiracy.
       ``(2) Applicable individual.--For purposes of paragraph 
     (1), the term `applicable individual' means an individual--
       ``(A) entitled to, or enrolled for, benefits under part A 
     of title XVIII or enrolled under part B of such title;
       ``(B) eligible for medical assistance under a State plan 
     under title XIX or under a waiver of such plan; or
       ``(C) eligible for child health assistance under a child 
     health plan under title XXI.
       ``(d) Reporting and Returning of Overpayments.--

[[Page 4373]]

       ``(1) In general.--If a person has received an overpayment, 
     the person shall--
       ``(A) report and return the overpayment to the Secretary, 
     the State, an intermediary, a carrier, or a contractor, as 
     appropriate, at the correct address; and
       ``(B) notify the Secretary, State, intermediary, carrier, 
     or contractor to whom the overpayment was returned in writing 
     of the reason for the overpayment.
       ``(2) Deadline for reporting and returning overpayments.--
     An overpayment must be reported and returned under paragraph 
     (1) by the later of--
       ``(A) the date which is 60 days after the date on which the 
     overpayment was identified; or
       ``(B) the date any corresponding cost report is due, if 
     applicable.
       ``(3) Enforcement.--Any overpayment retained by a person 
     after the deadline for reporting and returning the 
     overpayment under paragraph (2) is an obligation (as defined 
     in section 3729(b)(3) of title 31, United States Code) for 
     purposes of section 3729 of such title.
       ``(4) Definitions.--In this subsection:
       ``(A) Knowing and knowingly.--The terms `knowing' and 
     `knowingly' have the meaning given those terms in section 
     3729(b) of title 31, United States Code.
       ``(B) Overpayment.--The term ``overpayment'' means any 
     funds that a person receives or retains under title XVIII or 
     XIX to which the person, after applicable reconciliation, is 
     not entitled under such title.
       ``(C) Person.--
       ``(i) In general.--The term `person' means a provider of 
     services, supplier, medicaid managed care organization (as 
     defined in section 1903(m)(1)(A)), Medicare Advantage 
     organization (as defined in section 1859(a)(1)), or PDP 
     sponsor (as defined in section 1860D-41(a)(13)).
       ``(ii) Exclusion.--Such term does not include a 
     beneficiary.
       ``(e) Inclusion of National Provider Identifier on All 
     Applications and Claims.--The Secretary shall promulgate a 
     regulation that requires, not later than January 1, 2011, all 
     providers of medical or other items or services and suppliers 
     under the programs under titles XVIII and XIX that qualify 
     for a national provider identifier to include their national 
     provider identifier on all applications to enroll in such 
     programs and on all claims for payment submitted under such 
     programs.''.
       (b) Access to Data.--
       (1) Medicare part d.--Section 1860D-15(f)(2) of the Social 
     Security Act (42 U.S.C. 1395w-116(f)(2)) is amended by 
     striking ``may be used by'' and all that follows through the 
     period at the end and inserting ``may be used--
       ``(A) by officers, employees, and contractors of the 
     Department of Health and Human Services for the purposes of, 
     and to the extent necessary in--
       ``(i) carrying out this section; and
       ``(ii) conducting oversight, evaluation, and enforcement 
     under this title; and
       ``(B) by the Attorney General and the Comptroller General 
     of the United States for the purposes of, and to the extent 
     necessary in, carrying out health oversight activities.''.
       (2) Data matching.--Section 552a(a)(8)(B) of title 5, 
     United States Code, is amended--
       (A) in clause (vii), by striking ``or'' at the end;
       (B) in clause (viii), by inserting ``or'' after the 
     semicolon; and
       (C) by adding at the end the following new clause:
       ``(ix) matches performed by the Secretary of Health and 
     Human Services or the Inspector General of the Department of 
     Health and Human Services with respect to potential fraud, 
     waste, and abuse, including matches of a system of records 
     with non-Federal records;''.
       (3) Matching agreements with the commissioner of social 
     security.--Section 205(r) of the Social Security Act (42 
     U.S.C. 405(r)) is amended by adding at the end the following 
     new paragraph:
       ``(9)(A) The Commissioner of Social Security shall, upon 
     the request of the Secretary or the Inspector General of the 
     Department of Health and Human Services--
       ``(i) enter into an agreement with the Secretary or such 
     Inspector General for the purpose of matching data in the 
     system of records of the Social Security Administration and 
     the system of records of the Department of Health and Human 
     Services; and
       ``(ii) include in such agreement safeguards to assure the 
     maintenance of the confidentiality of any information 
     disclosed.
       ``(B) For purposes of this paragraph, the term `system of 
     records' has the meaning given such term in section 
     552a(a)(5) of title 5, United States Code.''.
       (c) Withholding of Federal Matching Payments for States 
     That Fail To Report Enrollee Encounter Data in the Medicaid 
     Statistical Information System.--Section 1903(i) of the 
     Social Security Act (42 U.S.C. 1396b(i)) is amended--
       (1) in paragraph (23), by striking ``or'' at the end;
       (2) in paragraph (24), by striking the period at the end 
     and inserting ``; or''; and
       (3) by adding at the end the following new paragraph:.
       ``(25) with respect to any amounts expended for medical 
     assistance for individuals for whom the State does not report 
     enrollee encounter data (as defined by the Secretary) to the 
     Medicaid Statistical Information System (MSIS) in a timely 
     manner (as determined by the Secretary).''.
       (d) Permissive Exclusions and Civil Monetary Penalties.--
       (1) Permissive exclusions.--Section 1128(b) of the Social 
     Security Act (42 U.S.C. 1320a-7(b)) is amended by adding at 
     the end the following new paragraph:
       ``(16) Making false statements or misrepresentation of 
     material facts.--Any individual or entity that knowingly 
     makes or causes to be made any false statement, omission, or 
     misrepresentation of a material fact in any application, 
     agreement, bid, or contract to participate or enroll as a 
     provider of services or supplier under a Federal health care 
     program (as defined in section 1128B(f)), including Medicare 
     Advantage organizations under part C of title XVIII, 
     prescription drug plan sponsors under part D of title XVIII, 
     medicaid managed care organizations under title XIX, and 
     entities that apply to participate as providers of services 
     or suppliers in such managed care organizations and such 
     plans.''.
       (2) Civil monetary penalties.--
       (A) In general.--Section 1128A(a) of the Social Security 
     Act (42 U.S.C. 1320a-7a(a)) is amended--
       (i) in paragraph (1)(D), by striking ``was excluded'' and 
     all that follows through the period at the end and inserting 
     ``was excluded from the Federal health care program (as 
     defined in section 1128B(f)) under which the claim was made 
     pursuant to Federal law.'';
       (ii) in paragraph (6), by striking ``or'' at the end;
       (iii) by inserting after paragraph (7), the following new 
     paragraphs:
       ``(8) orders or prescribes a medical or other item or 
     service during a period in which the person was excluded from 
     a Federal health care program (as so defined), in the case 
     where the person knows or should know that a claim for such 
     medical or other item or service will be made under such a 
     program;
       ``(9) knowingly makes or causes to be made any false 
     statement, omission, or misrepresentation of a material fact 
     in any application, bid, or contract to participate or enroll 
     as a provider of services or a supplier under a Federal 
     health care program (as so defined), including Medicare 
     Advantage organizations under part C of title XVIII, 
     prescription drug plan sponsors under part D of title XVIII, 
     medicaid managed care organizations under title XIX, and 
     entities that apply to participate as providers of services 
     or suppliers in such managed care organizations and such 
     plans;
       ``(10) knows of an overpayment (as defined in paragraph (4) 
     of section 1128J(d)) and does not report and return the 
     overpayment in accordance with such section;'';
       (iv) in the first sentence--

       (I) by striking the ``or'' after ``prohibited relationship 
     occurs;''; and
       (II) by striking ``act)'' and inserting ``act; or in cases 
     under paragraph (9), $50,000 for each false statement or 
     misrepresentation of a material fact)''; and

       (v) in the second sentence, by striking ``purpose)'' and 
     inserting ``purpose; or in cases under paragraph (9), an 
     assessment of not more than 3 times the total amount claimed 
     for each item or service for which payment was made based 
     upon the application containing the false statement or 
     misrepresentation of a material fact)''.
       (B) Clarification of treatment of certain charitable and 
     other innocuous programs.--Section 1128A(i)(6) of the Social 
     Security Act (42 U.S.C. 1320a-7a(i)(6)) is amended--
       (i) in subparagraph (C), by striking ``or'' at the end;
       (ii) in subparagraph (D), as redesignated by section 
     4331(e) of the Balanced Budget Act of 1997 (Public Law 105-
     33), by striking the period at the end and inserting a 
     semicolon;
       (iii) by redesignating subparagraph (D), as added by 
     section 4523(c) of such Act, as subparagraph (E) and striking 
     the period at the end and inserting ``; or''; and
       (iv) by adding at the end the following new subparagraphs:
       ``(F) any other remuneration which promotes access to care 
     and poses a low risk of harm to patients and Federal health 
     care programs (as defined in section 1128B(f) and designated 
     by the Secretary under regulations);
       ``(G) the offer or transfer of items or services for free 
     or less than fair market value by a person, if--
       ``(i) the items or services consist of coupons, rebates, or 
     other rewards from a retailer;
       ``(ii) the items or services are offered or transferred on 
     equal terms available to the general public, regardless of 
     health insurance status; and
       ``(iii) the offer or transfer of the items or services is 
     not tied to the provision of other items or services 
     reimbursed in whole or in part by the program under title 
     XVIII or a State health care program (as defined in section 
     1128(h));
       ``(H) the offer or transfer of items or services for free 
     or less than fair market value by a person, if--
       ``(i) the items or services are not offered as part of any 
     advertisement or solicitation;
       ``(ii) the items or services are not tied to the provision 
     of other services reimbursed in whole or in part by the 
     program under title XVIII or a State health care program (as 
     so defined);
       ``(iii) there is a reasonable connection between the items 
     or services and the medical care of the individual; and
       ``(iv) the person provides the items or services after 
     determining in good faith that the individual is in financial 
     need; or
       ``(I) effective on a date specified by the Secretary (but 
     not earlier than January 1, 2011), the waiver by a PDP 
     sponsor of a prescription

[[Page 4374]]

     drug plan under part D of title XVIII or an MA organization 
     offering an MA-PD plan under part C of such title of any 
     copayment for the first fill of a covered part D drug (as 
     defined in section 1860D-2(e)) that is a generic drug for 
     individuals enrolled in the prescription drug plan or MA-PD 
     plan, respectively.''.
       (e) Testimonial Subpoena Authority in Exclusion-only 
     Cases.--Section 1128(f) of the Social Security Act (42 U.S.C. 
     1320a-7(f)) is amended by adding at the end the following new 
     paragraph:
       ``(4) The provisions of subsections (d) and (e) of section 
     205 shall apply with respect to this section to the same 
     extent as they are applicable with respect to title II. The 
     Secretary may delegate the authority granted by section 
     205(d) (as made applicable to this section) to the Inspector 
     General of the Department of Health and Human Services for 
     purposes of any investigation under this section.''.
       (f) Health Care Fraud.--
       (1) Kickbacks.--Section 1128B of the Social Security Act 
     (42 U.S.C. 1320a-7b) is amended by adding at the end the 
     following new subsection:
       ``(g) In addition to the penalties provided for in this 
     section or section 1128A, a claim that includes items or 
     services resulting from a violation of this section 
     constitutes a false or fraudulent claim for purposes of 
     subchapter III of chapter 37 of title 31, United States 
     Code.''.
       (2) Revising the intent requirement.--Section 1128B of the 
     Social Security Act (42 U.S.C. 1320a-7b), as amended by 
     paragraph (1), is amended by adding at the end the following 
     new subsection:
       ``(h) With respect to violations of this section, a person 
     need not have actual knowledge of this section or specific 
     intent to commit a violation of this section.''.
       (g) Surety Bond Requirements.--
       (1) Durable medical equipment.--Section 1834(a)(16)(B) of 
     the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is 
     amended by inserting ``that the Secretary determines is 
     commensurate with the volume of the billing of the supplier'' 
     before the period at the end.
       (2) Home health agencies.--Section 1861(o)(7)(C) of the 
     Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by 
     inserting ``that the Secretary determines is commensurate 
     with the volume of the billing of the home health agency'' 
     before the semicolon at the end.
       (3) Requirements for certain other providers of services 
     and suppliers.--Section 1862 of the Social Security Act (42 
     U.S.C. 1395y) is amended by adding at the end the following 
     new subsection:
       ``(n) Requirement of a Surety Bond for Certain Providers of 
     Services and Suppliers.--
       ``(1) In general.--The Secretary may require a provider of 
     services or supplier described in paragraph (2) to provide 
     the Secretary on a continuing basis with a surety bond in a 
     form specified by the Secretary in an amount (not less than 
     $50,000) that the Secretary determines is commensurate with 
     the volume of the billing of the provider of services or 
     supplier. The Secretary may waive the requirement of a bond 
     under the preceding sentence in the case of a provider of 
     services or supplier that provides a comparable surety bond 
     under State law.
       ``(2) Provider of services or supplier described.--A 
     provider of services or supplier described in this paragraph 
     is a provider of services or supplier the Secretary 
     determines appropriate based on the level of risk involved 
     with respect to the provider of services or supplier, and 
     consistent with the surety bond requirements under sections 
     1834(a)(16)(B) and 1861(o)(7)(C).''.
       (h) Suspension of Medicare and Medicaid Payments Pending 
     Investigation of Credible Allegations of Fraud.--
       (1) Medicare.--Section 1862 of the Social Security Act (42 
     U.S.C. 1395y), as amended by subsection (g)(3), is amended by 
     adding at the end the following new subsection:
       ``(o) Suspension of Payments Pending Investigation of 
     Credible Allegations of Fraud.--
       ``(1) In general.--The Secretary may suspend payments to a 
     provider of services or supplier under this title pending an 
     investigation of a credible allegation of fraud against the 
     provider of services or supplier, unless the Secretary 
     determines there is good cause not to suspend such payments.
       ``(2) Consultation.--The Secretary shall consult with the 
     Inspector General of the Department of Health and Human 
     Services in determining whether there is a credible 
     allegation of fraud against a provider of services or 
     supplier.
       ``(3) Promulgation of regulations.--The Secretary shall 
     promulgate regulations to carry out this subsection and 
     section 1903(i)(2)(C).''.
       (2) Medicaid.--Section 1903(i)(2) of such Act (42 U.S.C. 
     1396b(i)(2)) is amended--
       (A) in subparagraph (A), by striking ``or'' at the end; and
       (B) by inserting after subparagraph (B), the following:
       ``(C) by any individual or entity to whom the State has 
     failed to suspend payments under the plan during any period 
     when there is pending an investigation of a credible 
     allegation of fraud against the individual or entity, as 
     determined by the State in accordance with regulations 
     promulgated by the Secretary for purposes of section 1862(o) 
     and this subparagraph, unless the State determines in 
     accordance with such regulations there is good cause not to 
     suspend such payments; or''.
       (i) Increased Funding To Fight Fraud and Abuse.--
       (1) In general.--Section 1817(k) of the Social Security Act 
     (42 U.S.C. 1395i(k)) is amended--
       (A) by adding at the end the following new paragraph:
       ``(7) Additional funding.--In addition to the funds 
     otherwise appropriated to the Account from the Trust Fund 
     under paragraphs (3) and (4) and for purposes described in 
     paragraphs (3)(C) and (4)(A), there are hereby appropriated 
     an additional $10,000,000 to such Account from such Trust 
     Fund for each of fiscal years 2011 through 2020. The funds 
     appropriated under this paragraph shall be allocated in the 
     same proportion as the total funding appropriated with 
     respect to paragraphs (3)(A) and (4)(A) was allocated with 
     respect to fiscal year 2010, and shall be available without 
     further appropriation until expended.''; and
       (B) in paragraph (4)(A), by inserting ``until expended'' 
     after ``appropriation''.
       (2) Indexing of amounts appropriated.--
       (A) Departments of health and human services and justice.--
     Section 1817(k)(3)(A)(i) of the Social Security Act (42 
     U.S.C. 1395i(k)(3)(A)(i)) is amended--
       (i) in subclause (III), by inserting ``and'' at the end;
       (ii) in subclause (IV)--

       (I) by striking ``for each of fiscal years 2007, 2008, 
     2009, and 2010'' and inserting ``for each fiscal year after 
     fiscal year 2006''; and
       (II) by striking ``; and'' and inserting a period; and

       (iii) by striking subclause (V).
       (B) Office of the inspector general of the department of 
     health and human services.--Section 1817(k)(3)(A)(ii) of such 
     Act (42 U.S.C. 1395i(k)(3)(A)(ii)) is amended--
       (i) in subclause (VIII), by inserting ``and'' at the end;
       (ii) in subclause (IX)--

       (I) by striking ``for each of fiscal years 2008, 2009, and 
     2010'' and inserting ``for each fiscal year after fiscal year 
     2007''; and
       (II) by striking ``; and'' and inserting a period; and

       (iii) by striking subclause (X).
       (C) Federal bureau of investigation.--Section 1817(k)(3)(B) 
     of the Social Security Act (42 U.S.C. 1395i(k)(3)(B)) is 
     amended--
       (i) in clause (vii), by inserting ``and'' at the end;
       (ii) in clause (viii)--

       (I) by striking ``for each of fiscal years 2007, 2008, 
     2009, and 2010'' and inserting ``for each fiscal year after 
     fiscal year 2006''; and
       (II) by striking ``; and'' and inserting a period; and

       (iii) by striking clause (ix).
       (D) Medicare integrity program.--Section 1817(k)(4)(C) of 
     the Social Security Act (42 U.S.C. 1395i(k)(4)(C)) is amended 
     by adding at the end the following new clause:
       ``(ii) For each fiscal year after 2010, by the percentage 
     increase in the consumer price index for all urban consumers 
     (all items; United States city average) over the previous 
     year.''.
       (j) Medicare Integrity Program and Medicaid Integrity 
     Program.--
       (1) Medicare integrity program.--
       (A) Requirement to provide performance statistics.--Section 
     1893(c) of the Social Security Act (42 U.S.C. 1395ddd(c)) is 
     amended--
       (i) in paragraph (3), by striking ``and'' at the end;
       (ii) by redesignating paragraph (4) as paragraph (5); and
       (iii) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) the entity agrees to provide the Secretary and the 
     Inspector General of the Department of Health and Human 
     Services with such performance statistics (including the 
     number and amount of overpayments recovered, the number of 
     fraud referrals, and the return on investment of such 
     activities by the entity) as the Secretary or the Inspector 
     General may request; and''.
       (B) Evaluations and annual report.--Section 1893 of the 
     Social Security Act (42 U.S.C. 1395ddd) is amended by adding 
     at the end the following new subsection:
       ``(i) Evaluations and Annual Report.--
       ``(1) Evaluations.--The Secretary shall conduct evaluations 
     of eligible entities which the Secretary contracts with under 
     the Program not less frequently than every 3 years.
       ``(2) Annual report.--Not later than 180 days after the end 
     of each fiscal year (beginning with fiscal year 2011), the 
     Secretary shall submit a report to Congress which 
     identifies--
       ``(A) the use of funds, including funds transferred from 
     the Federal Hospital Insurance Trust Fund under section 1817 
     and the Federal Supplementary Insurance Trust Fund under 
     section 1841, to carry out this section; and
       ``(B) the effectiveness of the use of such funds.''.
       (C) Flexibility in pursuing fraud and abuse.--Section 
     1893(a) of the Social Security Act (42 U.S.C. 1395ddd(a)) is 
     amended by inserting ``, or otherwise,'' after ``entities''.
       (2) Medicaid integrity program.--
       (A) Requirement to provide performance statistics.--Section 
     1936(c)(2) of the Social Security Act (42 U.S.C. 1396u-
     6(c)(2)) is amended--
       (i) by redesignating subparagraph (D) as subparagraph (E); 
     and
       (ii) by inserting after subparagraph (C) the following new 
     subparagraph:
       ``(D) The entity agrees to provide the Secretary and the 
     Inspector General of the Department of Health and Human 
     Services with such performance statistics (including the 
     number and amount of overpayments recovered, the number of 
     fraud referrals, and the return on investment of such 
     activities by the entity) as the Secretary or the Inspector 
     General may request.''.

[[Page 4375]]

       (B) Evaluations and annual report.--Section 1936(e) of the 
     Social Security Act (42 U.S.C. 1396u-7(e)) is amended--
       (i) by redesignating paragraph (4) as paragraph (5); and
       (ii) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) Evaluations.--The Secretary shall conduct evaluations 
     of eligible entities which the Secretary contracts with under 
     the Program not less frequently than every 3 years.''.
       (k) Expanded Application of Hardship Waivers for 
     Exclusions.--Section 1128(c)(3)(B) of the Social Security Act 
     (42 U.S.C. 1320a-7(c)(3)(B)) is amended by striking 
     ``individuals entitled to benefits under part A of title 
     XVIII or enrolled under part B of such title, or both'' and 
     inserting ``beneficiaries (as defined in section 1128A(i)(5)) 
     of that program''.

     SEC. 6403. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE 
                   INTEGRITY AND PROTECTION DATA BANK AND THE 
                   NATIONAL PRACTITIONER DATA BANK.

       (a) Information Reported by Federal Agencies and Health 
     Plans.--Section 1128E of the Social Security Act (42 U.S.C. 
     1320a-7e) is amended--
       (1) by striking subsection (a) and inserting the following:
       ``(a) In General.--The Secretary shall maintain a national 
     health care fraud and abuse data collection program under 
     this section for the reporting of certain final adverse 
     actions (not including settlements in which no findings of 
     liability have been made) against health care providers, 
     suppliers, or practitioners as required by subsection (b), 
     with access as set forth in subsection (d), and shall furnish 
     the information collected under this section to the National 
     Practitioner Data Bank established pursuant to the Health 
     Care Quality Improvement Act of 1986 (42 U.S.C. 11101 et 
     seq.).'';
       (2) by striking subsection (d) and inserting the following:
       ``(d) Access to Reported Information.--
       ``(1) Availability.--The information collected under this 
     section shall be available from the National Practitioner 
     Data Bank to the agencies, authorities, and officials which 
     are provided under section 1921(b) information reported under 
     section 1921(a).
       ``(2) Fees for disclosure.--The Secretary may establish or 
     approve reasonable fees for the disclosure of information 
     under this section. The amount of such a fee may not exceed 
     the costs of processing the requests for disclosure and of 
     providing such information. Such fees shall be available to 
     the Secretary to cover such costs.'';
       (3) by striking subsection (f) and inserting the following:
       ``(f) Appropriate Coordination.--In implementing this 
     section, the Secretary shall provide for the maximum 
     appropriate coordination with part B of the Health Care 
     Quality Improvement Act of 1986 (42 U.S.C. 11131 et seq.) and 
     section 1921.''; and
       (4) in subsection (g)--
       (A) in paragraph (1)(A)--
       (i) in clause (iii)--

       (I) by striking ``or State'' each place it appears;
       (II) by redesignating subclauses (II) and (III) as 
     subclauses (III) and (IV), respectively; and
       (III) by inserting after subclause (I) the following new 
     subclause:
       ``(II) any dismissal or closure of the proceedings by 
     reason of the provider, supplier, or practitioner 
     surrendering their license or leaving the State or 
     jurisdiction''; and

       (ii) by striking clause (iv) and inserting the following:
       ``(iv) Exclusion from participation in a Federal health 
     care program (as defined in section 1128B(f)).'';
       (B) in paragraph (3)--
       (i) by striking subparagraphs (D) and (E); and
       (ii) by redesignating subparagraph (F) as subparagraph (D); 
     and
       (C) in subparagraph (D) (as so redesignated), by striking 
     ``or State''.
       (b) Information Reported by State Law or Fraud Enforcement 
     Agencies.--Section 1921 of the Social Security Act (42 U.S.C. 
     1396r-2) is amended--
       (1) in subsection (a)--
       (A) in paragraph (1)--
       (i) by striking ``system.--The State'' and all that follows 
     through the semicolon and inserting system.--
       ``(A) Licensing or certification actions.--The State must 
     have in effect a system of reporting the following 
     information with respect to formal proceedings (as defined by 
     the Secretary in regulations) concluded against a health care 
     practitioner or entity by a State licensing or certification 
     agency:'';
       (ii) by redesignating subparagraphs (A) through (D) as 
     clauses (i) through (iv), respectively, and indenting 
     appropriately;
       (iii) in subparagraph (A)(iii) (as so redesignated)--

       (I) by striking ``the license of'' and inserting ``license 
     or the right to apply for, or renew, a license by''; and
       (II) by inserting ``nonrenewability,'' after ``voluntary 
     surrender,''; and

       (iv) by adding at the end the following new subparagraph:
       ``(B) Other final adverse actions.--The State must have in 
     effect a system of reporting information with respect to any 
     final adverse action (not including settlements in which no 
     findings of liability have been made) taken against a health 
     care provider, supplier, or practitioner by a State law or 
     fraud enforcement agency.''; and
       (B) in paragraph (2), by striking ``the authority described 
     in paragraph (1)'' and inserting ``a State licensing or 
     certification agency or State law or fraud enforcement 
     agency'';
       (2) in subsection (b)--
       (A) by striking paragraph (2) and inserting the following:
       ``(2) to State licensing or certification agencies and 
     Federal agencies responsible for the licensing and 
     certification of health care providers, suppliers, and 
     licensed health care practitioners;'';
       (B) in each of paragraphs (4) and (6), by inserting ``, but 
     only with respect to information provided pursuant to 
     subsection (a)(1)(A)'' before the comma at the end;
       (C) by striking paragraph (5) and inserting the following:
       ``(5) to State law or fraud enforcement agencies,'';
       (D) by redesignating paragraphs (7) and (8) as paragraphs 
     (8) and (9), respectively; and
       (E) by inserting after paragraph (6) the following new 
     paragraph:
       ``(7) to health plans (as defined in section 1128C(c));'';
       (3) by redesignating subsection (d) as subsection (h), and 
     by inserting after subsection (c) the following new 
     subsections:
       ``(d) Disclosure and Correction of Information.--
       ``(1) Disclosure.--With respect to information reported 
     pursuant to subsection (a)(1), the Secretary shall--
       ``(A) provide for disclosure of the information, upon 
     request, to the health care practitioner who, or the entity 
     that, is the subject of the information reported; and
       ``(B) establish procedures for the case where the health 
     care practitioner or entity disputes the accuracy of the 
     information reported.
       ``(2) Corrections.--Each State licensing or certification 
     agency and State law or fraud enforcement agency shall report 
     corrections of information already reported about any formal 
     proceeding or final adverse action described in subsection 
     (a), in such form and manner as the Secretary prescribes by 
     regulation.
       ``(e) Fees for Disclosure.--The Secretary may establish or 
     approve reasonable fees for the disclosure of information 
     under this section. The amount of such a fee may not exceed 
     the costs of processing the requests for disclosure and of 
     providing such information. Such fees shall be available to 
     the Secretary to cover such costs.
       ``(f) Protection From Liability for Reporting.--No person 
     or entity, including any agency designated by the Secretary 
     in subsection (b), shall be held liable in any civil action 
     with respect to any reporting of information as required 
     under this section, without knowledge of the falsity of the 
     information contained in the report.
       ``(g) References.--For purposes of this section:
       ``(1) State licensing or certification agency.--The term 
     `State licensing or certification agency' includes any 
     authority of a State (or of a political subdivision thereof) 
     responsible for the licensing of health care practitioners 
     (or any peer review organization or private accreditation 
     entity reviewing the services provided by health care 
     practitioners) or entities.
       ``(2) State law or fraud enforcement agency.--The term 
     `State law or fraud enforcement agency' includes--
       ``(A) a State law enforcement agency; and
       ``(B) a State medicaid fraud control unit (as defined in 
     section 1903(q)).
       ``(3) Final adverse action.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `final adverse action' includes--
       ``(i) civil judgments against a health care provider, 
     supplier, or practitioner in State court related to the 
     delivery of a health care item or service;
       ``(ii) State criminal convictions related to the delivery 
     of a health care item or service;
       ``(iii) exclusion from participation in State health care 
     programs (as defined in section 1128(h));
       ``(iv) any licensing or certification action described in 
     subsection (a)(1)(A) taken against a supplier by a State 
     licensing or certification agency; and
       ``(v) any other adjudicated actions or decisions that the 
     Secretary shall establish by regulation.
       ``(B) Exception.--Such term does not include any action 
     with respect to a malpractice claim.''; and
       (4) in subsection (h), as so redesignated, by striking 
     ``The Secretary'' and all that follows through the period at 
     the end and inserting ``In implementing this section, the 
     Secretary shall provide for the maximum appropriate 
     coordination with part B of the Health Care Quality 
     Improvement Act of 1986 (42 U.S.C. 11131 et seq.) and section 
     1128E.''.
       (c) Conforming Amendment.--Section 1128C(a)(1) of the 
     Social Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
       (1) in subparagraph (C), by adding ``and'' after the comma 
     at the end;
       (2) in subparagraph (D), by striking ``, and'' and 
     inserting a period; and
       (3) by striking subparagraph (E).
       (d) Transition Process; Effective Date.--
       (1) In general.--Effective on the date of enactment of this 
     Act, the Secretary of Health and Human Services (in this 
     section referred to as the ``Secretary'') shall implement a 
     transition process under which, by not later than the end of 
     the transition period described in paragraph (5), the 
     Secretary shall cease operating the Healthcare Integrity and 
     Protection Data Bank established under section 1128E of the 
     Social Security Act (as in effect before the effective date

[[Page 4376]]

     specified in paragraph (6)) and shall transfer all data 
     collected in the Healthcare Integrity and Protection Data 
     Bank to the National Practitioner Data Bank established 
     pursuant to the Health Care Quality Improvement Act of 1986 
     (42 U.S.C. 11101 et seq.). During such transition process, 
     the Secretary shall have in effect appropriate procedures to 
     ensure that data collection and access to the Healthcare 
     Integrity and Protection Data Bank and the National 
     Practitioner Data Bank are not disrupted.
       (2) Regulations.--The Secretary shall promulgate 
     regulations to carry out the amendments made by subsections 
     (a) and (b).
       (3) Funding.--
       (A) Availability of fees.--Fees collected pursuant to 
     section 1128E(d)(2) of the Social Security Act prior to the 
     effective date specified in paragraph (6) for the disclosure 
     of information in the Healthcare Integrity and Protection 
     Data Bank shall be available to the Secretary, without fiscal 
     year limitation, for payment of costs related to the 
     transition process described in paragraph (1). Any such fees 
     remaining after the transition period is complete shall be 
     available to the Secretary, without fiscal year limitation, 
     for payment of the costs of operating the National 
     Practitioner Data Bank.
       (B) Availability of additional funds.--In addition to the 
     fees described in subparagraph (A), any funds available to 
     the Secretary or to the Inspector General of the Department 
     of Health and Human Services for a purpose related to 
     combating health care fraud, waste, or abuse shall be 
     available to the extent necessary for operating the 
     Healthcare Integrity and Protection Data Bank during the 
     transition period, including systems testing and other 
     activities necessary to ensure that information formerly 
     reported to the Healthcare Integrity and Protection Data Bank 
     will be accessible through the National Practitioner Data 
     Bank after the end of such transition period.
       (4) Special provision for access to the national 
     practitioner data bank by the department of veterans 
     affairs.--
       (A) In general.--Notwithstanding any other provision of 
     law, during the 1-year period that begins on the effective 
     date specified in paragraph (6), the information described in 
     subparagraph (B) shall be available from the National 
     Practitioner Data Bank to the Secretary of Veterans Affairs 
     without charge.
       (B) Information described.--For purposes of subparagraph 
     (A), the information described in this subparagraph is the 
     information that would, but for the amendments made by this 
     section, have been available to the Secretary of Veterans 
     Affairs from the Healthcare Integrity and Protection Data 
     Bank.
       (5) Transition period defined.--For purposes of this 
     subsection, the term ``transition period'' means the period 
     that begins on the date of enactment of this Act and ends on 
     the later of--
       (A) the date that is 1 year after such date of enactment; 
     or
       (B) the effective date of the regulations promulgated under 
     paragraph (2).
       (6) Effective date.--The amendments made by subsections 
     (a), (b), and (c) shall take effect on the first day after 
     the final day of the transition period.

     SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS 
                   REDUCED TO NOT MORE THAN 12 MONTHS.

       (a) Reducing Maximum Period for Submission.--
       (1) Part a.--Section 1814(a) of the Social Security Act (42 
     U.S.C. 1395f(a)(1)) is amended--
       (A) in paragraph (1), by striking ``period of 3 calendar 
     years'' and all that follows through the semicolon and 
     inserting ``period ending 1 calendar year after the date of 
     service;''; and
       (B) by adding at the end the following new sentence: ``In 
     applying paragraph (1), the Secretary may specify exceptions 
     to the 1 calendar year period specified in such paragraph.''
       (2) Part b.--
       (A) Section 1842(b)(3) of such Act (42 U.S.C. 
     1395u(b)(3)(B)) is amended--
       (i) in subparagraph (B), in the flush language following 
     clause (ii), by striking ``close of the calendar year 
     following the year in which such service is furnished 
     (deeming any service furnished in the last 3 months of any 
     calendar year to have been furnished in the succeeding 
     calendar year)'' and inserting ``period ending 1 calendar 
     year after the date of service''; and
       (ii) by adding at the end the following new sentence: ``In 
     applying subparagraph (B), the Secretary may specify 
     exceptions to the 1 calendar year period specified in such 
     subparagraph.''
       (B) Section 1835(a) of such Act (42 U.S.C. 1395n(a)) is 
     amended--
       (i) in paragraph (1), by striking ``period of 3 calendar 
     years'' and all that follows through the semicolon and 
     inserting ``period ending 1 calendar year after the date of 
     service;''; and
       (ii) by adding at the end the following new sentence: ``In 
     applying paragraph (1), the Secretary may specify exceptions 
     to the 1 calendar year period specified in such paragraph.''
       (b) Effective Date.--
       (1) In general.--The amendments made by subsection (a) 
     shall apply to services furnished on or after January 1, 
     2010.
       (2) Services furnished before 2010.--In the case of 
     services furnished before January 1, 2010, a bill or request 
     for payment under section 1814(a)(1), 1842(b)(3)(B), or 
     1835(a) shall be filed not later that December 31, 2010.

     SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED TO 
                   BE MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE 
                   PROFESSIONALS.

       (a) DME.--Section 1834(a)(11)(B) of the Social Security Act 
     (42 U.S.C. 1395m(a)(11)(B)) is amended by striking 
     ``physician'' and inserting ``physician enrolled under 
     section 1866(j) or an eligible professional under section 
     1848(k)(3)(B) that is enrolled under section 1866(j)''.
       (b) Home Health Services.--
       (1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C. 
     1395(a)(2)) is amended in the matter preceding subparagraph 
     (A) by inserting ``in the case of services described in 
     subparagraph (C), a physician enrolled under section 1866(j) 
     or an eligible professional under section 1848(k)(3)(B),'' 
     before ``or, in the case of services''.
       (2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C. 
     1395n(a)(2)) is amended in the matter preceding subparagraph 
     (A) by inserting ``, or in the case of services described in 
     subparagraph (A), a physician enrolled under section 1866(j) 
     or an eligible professional under section 1848(k)(3)(B),'' 
     after ``a physician''.
       (c) Application to Other Items or Services.--The Secretary 
     may extend the requirement applied by the amendments made by 
     subsections (a) and (b) to durable medical equipment and home 
     health services (relating to requiring certifications and 
     written orders to be made by enrolled physicians and health 
     professions) to all other categories of items or services 
     under title XVIII of the Social Security Act (42 U.S.C. 1395 
     et seq.), including covered part D drugs as defined in 
     section 1860D-2(e) of such Act (42 U.S.C. 1395w-102), that 
     are ordered, prescribed, or referred by a physician enrolled 
     under section 1866(j) of such Act (42 U.S.C. 1395cc(j)) or an 
     eligible professional under section 1848(k)(3)(B) of such Act 
     (42 U.S.C. 1395w-4(k)(3)(B)).
       (d) Effective Date.--The amendments made by this section 
     shall apply to written orders and certifications made on or 
     after July 1, 2010.

     SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE 
                   DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH 
                   RISK OF WASTE AND ABUSE.

       (a) Physicians and Other Suppliers.--Section 1842(h) of the 
     Social Security Act (42 U.S.C. 1395u(h)) is amended by adding 
     at the end the following new paragraph:
       ``(9) The Secretary may revoke enrollment, for a period of 
     not more than one year for each act, for a physician or 
     supplier under section 1866(j) if such physician or supplier 
     fails to maintain and, upon request of the Secretary, provide 
     access to documentation relating to written orders or 
     requests for payment for durable medical equipment, 
     certifications for home health services, or referrals for 
     other items or services written or ordered by such physician 
     or supplier under this title, as specified by the 
     Secretary.''.
       (b) Providers of Services.--Section 1866(a)(1) of such Act 
     (42 U.S.C. 1395cc) is further amended--
       (1) in subparagraph (U), by striking at the end ``and'';
       (2) in subparagraph (V), by striking the period at the end 
     and adding ``; and''; and
       (3) by adding at the end the following new subparagraph:
       ``(W) maintain and, upon request of the Secretary, provide 
     access to documentation relating to written orders or 
     requests for payment for durable medical equipment, 
     certifications for home health services, or referrals for 
     other items or services written or ordered by the provider 
     under this title, as specified by the Secretary.''.
       (c) OIG Permissive Exclusion Authority.--Section 
     1128(b)(11) of the Social Security Act (42 U.S.C. 1320a-
     7(b)(11)) is amended by inserting ``, ordering, referring for 
     furnishing, or certifying the need for'' after 
     ``furnishing''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to orders, certifications, and referrals made on 
     or after January 1, 2010.

     SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED 
                   BEFORE PHYSICIANS MAY CERTIFY ELIGIBILITY FOR 
                   HOME HEALTH SERVICES OR DURABLE MEDICAL 
                   EQUIPMENT UNDER MEDICARE.

       (a) Condition of Payment for Home Health Services.--
       (1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
       (A) by striking ``and such services'' and inserting ``such 
     services''; and
       (B) by inserting after ``care of a physician'' the 
     following: ``, and, in the case of a certification made by a 
     physician after January 1, 2010, prior to making such 
     certification the physician must document that the physician 
     himself or herself has had a face-to-face encounter 
     (including through use of telehealth, subject to the 
     requirements in section 1834(m), and other than with respect 
     to encounters that are incident to services involved) with 
     the individual within a reasonable timeframe as determined by 
     the Secretary''.
       (2) Part b.--Section 1835(a)(2)(A) of the Social Security 
     Act is amended--
       (A) by striking ``and'' before ``(iii)''; and
       (B) by inserting after ``care of a physician'' the 
     following: ``, and (iv) in the case of a certification after 
     January 1, 2010, prior to making such certification the 
     physician must document that the physician has had a face-to-
     face encounter (including through use of telehealth and other 
     than with respect to encounters that are incident to services 
     involved) with the individual during the 6-month period 
     preceding such certification, or other reasonable timeframe 
     as determined by the Secretary''.
       (b) Condition of Payment for Durable Medical Equipment.--
     Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 
     1395m(a)(11)(B)) is amended--

[[Page 4377]]

       (1) by striking ``Order.--The Secretary'' and inserting 
     ``Order.--
       ``(i) In general.--The Secretary''; and
       (2) by adding at the end the following new clause:
       ``(ii) Requirement for face to face encounter.--The 
     Secretary shall require that such an order be written 
     pursuant to the physician documenting that a physician, a 
     physician assistant, a nurse practitioner, or a clinical 
     nurse specialist (as those terms are defined in section 
     1861(aa)(5)) has had a face-to-face encounter (including 
     through use of telehealth under subsection (m) and other than 
     with respect to encounters that are incident to services 
     involved) with the individual involved during the 6-month 
     period preceding such written order, or other reasonable 
     timeframe as determined by the Secretary.''.
       (c) Application to Other Areas Under Medicare.--The 
     Secretary may apply the face-to-face encounter requirement 
     described in the amendments made by subsections (a) and (b) 
     to other items and services for which payment is provided 
     under title XVIII of the Social Security Act based upon a 
     finding that such an decision would reduce the risk of waste, 
     fraud, or abuse.
       (d) Application to Medicaid.--The requirements pursuant to 
     the amendments made by subsections (a) and (b) shall apply in 
     the case of physicians making certifications for home health 
     services under title XIX of the Social Security Act in the 
     same manner and to the same extent as such requirements apply 
     in the case of physicians making such certifications under 
     title XVIII of such Act.

     SEC. 6408. ENHANCED PENALTIES.

       (a) Civil Monetary Penalties for False Statements or 
     Delaying Inspections.--Section 1128A(a) of the Social 
     Security Act (42 U.S.C. 1320a-7a(a)), as amended by section 
     5002(d)(2)(A), is amended--
       (1) in paragraph (6), by striking ``or'' at the end; and
       (2) by inserting after paragraph (7) the following new 
     paragraphs:
       ``(8) knowingly makes, uses, or causes to be made or used, 
     a false record or statement material to a false or fraudulent 
     claim for payment for items and services furnished under a 
     Federal health care program; or
       ``(9) fails to grant timely access, upon reasonable request 
     (as defined by the Secretary in regulations), to the 
     Inspector General of the Department of Health and Human 
     Services, for the purpose of audits, investigations, 
     evaluations, or other statutory functions of the Inspector 
     General of the Department of Health and Human Services;''; 
     and
       (3) in the first sentence--
       (A) by striking ``or in cases under paragraph (7)'' and 
     inserting ``in cases under paragraph (7)''; and
       (B) by striking ``act)'' and inserting ``act, in cases 
     under paragraph (8), $50,000 for each false record or 
     statement, or in cases under paragraph (9), $15,000 for each 
     day of the failure described in such paragraph)''.
       (b) Medicare Advantage and Part D Plans.--
       (1) Ensuring timely inspections relating to contracts with 
     ma organizations.--Section 1857(d)(2) of such Act (42 U.S.C. 
     1395w-27(d)(2)) is amended--
       (A) in subparagraph (A), by inserting ``timely'' before 
     ``inspect''; and
       (B) in subparagraph (B), by inserting ``timely'' before 
     ``audit and inspect''.
       (2) Marketing violations.--Section 1857(g)(1) of the Social 
     Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
       (A) in subparagraph (F), by striking ``or'' at the end;
       (B) by inserting after subparagraph (G) the following new 
     subparagraphs:
       ``(H) except as provided under subparagraph (C) or (D) of 
     section 1860D-1(b)(1), enrolls an individual in any plan 
     under this part without the prior consent of the individual 
     or the designee of the individual;
       ``(I) transfers an individual enrolled under this part from 
     one plan to another without the prior consent of the 
     individual or the designee of the individual or solely for 
     the purpose of earning a commission;
       ``(J) fails to comply with marketing restrictions described 
     in subsections (h) and (j) of section 1851 or applicable 
     implementing regulations or guidance; or
       ``(K) employs or contracts with any individual or entity 
     who engages in the conduct described in subparagraphs (A) 
     through (J) of this paragraph;''; and
       (C) by adding at the end the following new sentence: ``The 
     Secretary may provide, in addition to any other remedies 
     authorized by law, for any of the remedies described in 
     paragraph (2), if the Secretary determines that any employee 
     or agent of such organization, or any provider or supplier 
     who contracts with such organization, has engaged in any 
     conduct described in subparagraphs (A) through (K) of this 
     paragraph.''.
       (3) Provision of false information.--Section 1857(g)(2)(A) 
     of the Social Security Act (42 U.S.C. 1395w-27(g)(2)(A)) is 
     amended by inserting ``except with respect to a determination 
     under subparagraph (E), an assessment of not more than the 
     amount claimed by such plan or plan sponsor based upon the 
     misrepresentation or falsified information involved,'' after 
     ``for each such determination,''.
       (c) Obstruction of Program Audits.--Section 1128(b)(2) of 
     the Social Security Act (42 U.S.C. 1320a-7(b)(2)) is 
     amended--
       (1) in the heading, by inserting ``or audit'' after 
     ``investigation''; and
       (2) by striking ``investigation into'' and all that follows 
     through the period and inserting ``investigation or audit 
     related to--''
       ``(i) any offense described in paragraph (1) or in 
     subsection (a); or
       ``(ii) the use of funds received, directly or indirectly, 
     from any Federal health care program (as defined in section 
     1128B(f)).''.
       (d) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by this section shall apply to acts committed 
     on or after January 1, 2010.
       (2) Exception.--The amendments made by subsection (b)(1) 
     take effect on the date of enactment of this Act.

     SEC. 6409. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL.

       (a) Development of Self-Referral Disclosure Protocol.--
       (1) In general.--The Secretary of Health and Human 
     Services, in cooperation with the Inspector General of the 
     Department of Health and Human Services, shall establish, not 
     later than 6 months after the date of the enactment of this 
     Act, a protocol to enable health care providers of services 
     and suppliers to disclose an actual or potential violation of 
     section 1877 of the Social Security Act (42 U.S.C. 1395nn) 
     pursuant to a self-referral disclosure protocol (in this 
     section referred to as an ``SRDP''). The SRDP shall include 
     direction to health care providers of services and suppliers 
     on--
       (A) a specific person, official, or office to whom such 
     disclosures shall be made; and
       (B) instruction on the implication of the SRDP on corporate 
     integrity agreements and corporate compliance agreements.
       (2) Publication on internet website of srdp information.--
     The Secretary of Health and Human Services shall post 
     information on the public Internet website of the Centers for 
     Medicare & Medicaid Services to inform relevant stakeholders 
     of how to disclose actual or potential violations pursuant to 
     an SRDP.
       (3) Relation to advisory opinions.--The SRDP shall be 
     separate from the advisory opinion process set forth in 
     regulations implementing section 1877(g) of the Social 
     Security Act.
       (b) Reduction in Amounts Owed.--The Secretary of Health and 
     Human Services is authorized to reduce the amount due and 
     owing for all violations under section 1877 of the Social 
     Security Act to an amount less than that specified in 
     subsection (g) of such section. In establishing such amount 
     for a violation, the Secretary may consider the following 
     factors:
       (1) The nature and extent of the improper or illegal 
     practice.
       (2) The timeliness of such self-disclosure.
       (3) The cooperation in providing additional information 
     related to the disclosure.
       (4) Such other factors as the Secretary considers 
     appropriate.
       (c) Report.--Not later than 18 months after the date on 
     which the SRDP protocol is established under subsection 
     (a)(1), the Secretary shall submit to Congress a report on 
     the implementation of this section. Such report shall 
     include--
       (1) the number of health care providers of services and 
     suppliers making disclosures pursuant to the SRDP;
       (2) the amounts collected pursuant to the SRDP;
       (3) the types of violations reported under the SRDP; and
       (4) such other information as may be necessary to evaluate 
     the impact of this section.

     SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL 
                   EQUIPMENT, PROSTHETICS, ORTHOTICS, AND SUPPLIES 
                   COMPETITIVE ACQUISITION PROGRAM.

       (a) Expansion of Round 2 of the DME Competitive Bidding 
     Program.--Section 1847(a)(1) of the Social Security Act (42 
     U.S.C. 1395w-3(a)(1)) is amended--
       (1) in subparagraph (B)(i)(II), by striking ``70'' and 
     inserting ``91''; and
       (2) in subparagraph (D)(ii)--
       (A) in subclause (I), by striking ``and'' at the end;
       (B) by redesignating subclause (II) as subclause (III); and
       (C) by inserting after subclause (I) the following new 
     subclause:

       ``(II) the Secretary shall include the next 21 largest 
     metropolitan statistical areas by total population (after 
     those selected under subclause (I)) for such round; and''.

       (b) Requirement to Either Competitively Bid Areas or Use 
     Competitive Bid Prices by 2016.--Section 1834(a)(1)(F) of the 
     Social Security Act (42 U.S.C. 1395m(a)(1)(F)) is amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) in clause (ii)--
       (A) by inserting ``(and, in the case of covered items 
     furnished on or after January 1, 2016, subject to clause 
     (iii), shall)'' after ``may''; and
       (B) by striking the period at the end and inserting ``; 
     and''; and
       (3) by adding at the end the following new clause:
       ``(iii) in the case of covered items furnished on or after 
     January 1, 2016, the Secretary shall continue to make such 
     adjustments described in clause (ii) as, under such 
     competitive acquisition programs, additional covered items 
     are phased in or information is updated as contracts under 
     section 1847 are recompeted in accordance with section 
     1847(b)(3)(B).''.

     SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) 
                   PROGRAM.

       (a) Expansion to Medicaid.--
       (1) State plan amendment.--Section 1902(a)(42) of the 
     Social Security Act (42 U.S.C. 1396a(a)(42)) is amended--

[[Page 4378]]

       (A) by striking ``that the records'' and inserting ``that--
       ``(A) the records'';
       (B) by inserting ``and'' after the semicolon; and
       (C) by adding at the end the following:
       ``(B) not later than December 31, 2010, the State shall--
       ``(i) establish a program under which the State contracts 
     (consistent with State law and in the same manner as the 
     Secretary enters into contracts with recovery audit 
     contractors under section 1893(h), subject to such exceptions 
     or requirements as the Secretary may require for purposes of 
     this title or a particular State) with 1 or more recovery 
     audit contractors for the purpose of identifying 
     underpayments and overpayments and recouping overpayments 
     under the State plan and under any waiver of the State plan 
     with respect to all services for which payment is made to any 
     entity under such plan or waiver; and
       ``(ii) provide assurances satisfactory to the Secretary 
     that--

       ``(I) under such contracts, payment shall be made to such a 
     contractor only from amounts recovered;
       ``(II) from such amounts recovered, payment--

       ``(aa) shall be made on a contingent basis for collecting 
     overpayments; and
       ``(bb) may be made in such amounts as the State may specify 
     for identifying underpayments;

       ``(III) the State has an adequate process for entities to 
     appeal any adverse determination made by such contractors; 
     and
       ``(IV) such program is carried out in accordance with such 
     requirements as the Secretary shall specify, including--

       ``(aa) for purposes of section 1903(a)(7), that amounts 
     expended by the State to carry out the program shall be 
     considered amounts expended as necessary for the proper and 
     efficient administration of the State plan or a waiver of the 
     plan;
       ``(bb) that section 1903(d) shall apply to amounts 
     recovered under the program; and
       ``(cc) that the State and any such contractors under 
     contract with the State shall coordinate such recovery audit 
     efforts with other contractors or entities performing audits 
     of entities receiving payments under the State plan or waiver 
     in the State, including efforts with Federal and State law 
     enforcement with respect to the Department of Justice, 
     including the Federal Bureau of Investigations, the Inspector 
     General of the Department of Health and Human Services, and 
     the State medicaid fraud control unit; and''.
       (2) Coordination; regulations.--
       (A) In general.--The Secretary of Health and Human 
     Services, acting through the Administrator of the Centers for 
     Medicare & Medicaid Services, shall coordinate the expansion 
     of the Recovery Audit Contractor program to Medicaid with 
     States, particularly with respect to each State that enters 
     into a contract with a recovery audit contractor for purposes 
     of the State's Medicaid program prior to December 31, 2010.
       (B) Regulations.--The Secretary of Health and Human 
     Services shall promulgate regulations to carry out this 
     subsection and the amendments made by this subsection, 
     including with respect to conditions of Federal financial 
     participation, as specified by the Secretary.
       (b) Expansion to Medicare Parts C and D.--Section 1893(h) 
     of the Social Security Act (42 U.S.C. 1395ddd(h)) is 
     amended--
       (1) in paragraph (1), in the matter preceding subparagraph 
     (A), by striking ``part A or B'' and inserting ``this 
     title'';
       (2) in paragraph (2), by striking ``parts A and B'' and 
     inserting ``this title'';
       (3) in paragraph (3), by inserting ``(not later than 
     December 31, 2010, in the case of contracts relating to 
     payments made under part C or D)'' after ``2010'';
       (4) in paragraph (4), in the matter preceding subparagraph 
     (A), by striking ``part A or B'' and inserting ``this 
     title''; and
       (5) by adding at the end the following:
       ``(9) Special rules relating to parts c and d.--The 
     Secretary shall enter into contracts under paragraph (1) to 
     require recovery audit contractors to--
       ``(A) ensure that each MA plan under part C has an anti-
     fraud plan in effect and to review the effectiveness of each 
     such anti-fraud plan;
       ``(B) ensure that each prescription drug plan under part D 
     has an anti-fraud plan in effect and to review the 
     effectiveness of each such anti-fraud plan;
       ``(C) examine claims for reinsurance payments under section 
     1860D-15(b) to determine whether prescription drug plans 
     submitting such claims incurred costs in excess of the 
     allowable reinsurance costs permitted under paragraph (2) of 
     that section; and
       ``(D) review estimates submitted by prescription drug plans 
     by private plans with respect to the enrollment of high cost 
     beneficiaries (as defined by the Secretary) and to compare 
     such estimates with the numbers of such beneficiaries 
     actually enrolled by such plans.''.
       (c) Annual Report.--The Secretary of Health and Human 
     Services, acting through the Administrator of the Centers for 
     Medicare & Medicaid Services, shall submit an annual report 
     to Congress concerning the effectiveness of the Recovery 
     Audit Contractor program under Medicaid and Medicare and 
     shall include such reports recommendations for expanding or 
     improving the program.

      Subtitle F--Additional Medicaid Program Integrity Provisions

     SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER 
                   MEDICAID IF TERMINATED UNDER MEDICARE OR OTHER 
                   STATE PLAN.

       Section 1902(a)(39) of the Social Security Act (42 U.S.C. 
     42 U.S.C. 1396a(a)) is amended by inserting after ``1128A,'' 
     the following: ``terminate the participation of any 
     individual or entity in such program if (subject to such 
     exceptions as are permitted with respect to exclusion under 
     sections 1128(c)(3)(B) and 1128(d)(3)(B)) participation of 
     such individual or entity is terminated under title XVIII or 
     any other State plan under this title,''.

     SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO 
                   CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT 
                   AFFILIATIONS.

       Section 1902(a) of the Social Security Act (42 U.S.C. 
     1396a(a)), as amended by section 6401(b), is amended by 
     inserting after paragraph (77) the following:
       ``(78) provide that the State agency described in paragraph 
     (9) exclude, with respect to a period, any individual or 
     entity from participation in the program under the State plan 
     if such individual or entity owns, controls, or manages an 
     entity that (or if such entity is owned, controlled, or 
     managed by an individual or entity that)--
       ``(A) has unpaid overpayments (as defined by the Secretary) 
     under this title during such period determined by the 
     Secretary or the State agency to be delinquent;
       ``(B) is suspended or excluded from participation under or 
     whose participation is terminated under this title during 
     such period; or
       ``(C) is affiliated with an individual or entity that has 
     been suspended or excluded from participation under this 
     title or whose participation is terminated under this title 
     during such period;''.

     SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE 
                   PAYEES REQUIRED TO REGISTER UNDER MEDICAID.

       (a) In General.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by section 
     6502(a), is amended by inserting after paragraph (78), the 
     following:
       ``(79) provide that any agent, clearinghouse, or other 
     alternate payee (as defined by the Secretary) that submits 
     claims on behalf of a health care provider must register with 
     the State and the Secretary in a form and manner specified by 
     the Secretary;''.

     SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA 
                   ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE.

       (a) In General.--Section 1903(r)(1)(F) of the Social 
     Security Act (42 U.S.C. 1396b(r)(1)(F)) is amended by 
     inserting after ``necessary'' the following: ``and including, 
     for data submitted to the Secretary on or after January 1, 
     2010, data elements from the automated data system that the 
     Secretary determines to be necessary for program integrity, 
     program oversight, and administration, at such frequency as 
     the Secretary shall determine''.
       (b) Managed Care Organizations.--
       (1) In general.--Section 1903(m)(2)(A)(xi) of the Social 
     Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by 
     inserting ``and for the provision of such data to the State 
     at a frequency and level of detail to be specified by the 
     Secretary'' after ``patients''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply with respect to contract years beginning on or 
     after January 1, 2010.

     SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR 
                   ENTITIES LOCATED OUTSIDE OF THE UNITED STATES.

       Section 1902(a) of the Social Security Act (42 U.S.C. 
     1396b(a)), as amended by section 6503, is amended by 
     inserting after paragraph (79) the following new paragraph:
       ``(80) provide that the State shall not provide any 
     payments for items or services provided under the State plan 
     or under a waiver to any financial institution or entity 
     located outside of the United States;''.

     SEC. 6506. OVERPAYMENTS.

       (a) Extension of Period for Collection of Overpayments Due 
     to Fraud.--
       (1) In general.--Section 1903(d)(2) of the Social Security 
     Act (42 U.S.C. 1396b(d)(2)) is amended--
       (A) in subparagraph (C)--
       (i) in the first sentence, by striking ``60 days'' and 
     inserting ``1 year''; and
       (ii) in the second sentence, by striking ``60 days'' and 
     inserting ``1-year period''; and
       (B) in subparagraph (D)--
       (i) in inserting ``(i)'' after ``(D)''; and
       (ii) by adding at the end the following:
       ``(ii) In any case where the State is unable to recover a 
     debt which represents an overpayment (or any portion thereof) 
     made to a person or other entity due to fraud within 1 year 
     of discovery because there is not a final determination of 
     the amount of the overpayment under an administrative or 
     judicial process (as applicable), including as a result of a 
     judgment being under appeal, no adjustment shall be made in 
     the Federal payment to such State on account of such 
     overpayment (or portion thereof) before the date that is 30 
     days after the date on which a final judgment (including, if 
     applicable, a final determination on an appeal) is made.''.
       (2) Effective date.--The amendments made by this subsection 
     take effect on the date of enactment of this Act and apply to 
     overpayments discovered on or after that date.
       (b) Corrective Action.--The Secretary shall promulgate 
     regulations that require States to

[[Page 4379]]

     correct Federally identified claims overpayments, of an 
     ongoing or recurring nature, with new Medicaid Management 
     Information System (MMIS) edits, audits, or other appropriate 
     corrective action.

     SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING 
                   INITIATIVE.

       Section 1903(r) of the Social Security Act (42 U.S.C. 
     1396b(r)) is amended--
       (1) in paragraph (1)(B)--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) in clause (iii), by adding ``and'' after the semi-
     colon; and
       (C) by adding at the end the following new clause:
       ``(iv) effective for claims filed on or after October 1, 
     2010, incorporate compatible methodologies of the National 
     Correct Coding Initiative administered by the Secretary (or 
     any successor initiative to promote correct coding and to 
     control improper coding leading to inappropriate payment) and 
     such other methodologies of that Initiative (or such other 
     national correct coding methodologies) as the Secretary 
     identifies in accordance with paragraph (4);''; and
       (2) by adding at the end the following new paragraph:
       ``(4) For purposes of paragraph (1)(B)(iv), the Secretary 
     shall do the following:
       ``(A) Not later than September 1, 2010:
       ``(i) Identify those methodologies of the National Correct 
     Coding Initiative administered by the Secretary (or any 
     successor initiative to promote correct coding and to control 
     improper coding leading to inappropriate payment) which are 
     compatible to claims filed under this title.
       ``(ii) Identify those methodologies of such Initiative (or 
     such other national correct coding methodologies) that should 
     be incorporated into claims filed under this title with 
     respect to items or services for which States provide medical 
     assistance under this title and no national correct coding 
     methodologies have been established under such Initiative 
     with respect to title XVIII.
       ``(iii) Notify States of--
       ``(I) the methodologies identified under subparagraphs (A) 
     and (B) (and of any other national correct coding 
     methodologies identified under subparagraph (B)); and
       ``(II) how States are to incorporate such methodologies 
     into claims filed under this title.
       ``(B) Not later than March 1, 2011, submit a report to 
     Congress that includes the notice to States under clause 
     (iii) of subparagraph (A) and an analysis supporting the 
     identification of the methodologies made under clauses (i) 
     and (ii) of subparagraph (A).''.

     SEC. 6508. GENERAL EFFECTIVE DATE.

       (a) In General.--Except as otherwise provided in this 
     subtitle, this subtitle and the amendments made by this 
     subtitle take effect on January 1, 2011, without regard to 
     whether final regulations to carry out such amendments and 
     subtitle have been promulgated by that date.
       (b) Delay if State Legislation Required.--In the case of a 
     State plan for medical assistance under title XIX of the 
     Social Security Act or a child health plan under title XXI of 
     such Act which the Secretary of Health and Human Services 
     determines requires State legislation (other than legislation 
     appropriating funds) in order for the plan to meet the 
     additional requirement imposed by the amendments made by this 
     subtitle, the State plan or child health plan shall not be 
     regarded as failing to comply with the requirements of such 
     title solely on the basis of its failure to meet this 
     additional requirement before the first day of the first 
     calendar quarter beginning after the close of the first 
     regular session of the State legislature that begins after 
     the date of the enactment of this Act. For purposes of the 
     previous sentence, in the case of a State that has a 2-year 
     legislative session, each year of such session shall be 
     deemed to be a separate regular session of the State 
     legislature.

          Subtitle G--Additional Program Integrity Provisions

     SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND 
                   REPRESENTATIONS.

       (a) Prohibition.--Part 5 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 (29 U.S.C. 
     1131 et seq.) is amended by adding at the end the following:

     ``SEC. 519. PROHIBITION ON FALSE STATEMENTS AND 
                   REPRESENTATIONS.

       ``No person, in connection with a plan or other arrangement 
     that is multiple employer welfare arrangement described in 
     section 3(40), shall make a false statement or false 
     representation of fact, knowing it to be false, in connection 
     with the marketing or sale of such plan or arrangement, to 
     any employee, any member of an employee organization, any 
     beneficiary, any employer, any employee organization, the 
     Secretary, or any State, or the representative or agent of 
     any such person, State, or the Secretary, concerning--
       ``(1) the financial condition or solvency of such plan or 
     arrangement;
       ``(2) the benefits provided by such plan or arrangement;
       ``(3) the regulatory status of such plan or other 
     arrangement under any Federal or State law governing 
     collective bargaining, labor management relations, or intern 
     union affairs; or
       ``(4) the regulatory status of such plan or other 
     arrangement regarding exemption from state regulatory 
     authority under this Act.
     This section shall not apply to any plan or arrangement that 
     does not fall within the meaning of the term `multiple 
     employer welfare arrangement' under section 3(40)(A).''.
       (b) Criminal Penalties.--Section 501 of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 1131) is 
     amended--
       (1) by inserting ``(a)'' before ``Any person''; and
       (2) by adding at the end the following:
       ``(b) Any person that violates section 519 shall upon 
     conviction be imprisoned not more than 10 years or fined 
     under title 18, United States Code, or both.''.
       (c) Conforming Amendment.--The table of sections for part 5 
     of subtitle B of title I of the Employee Retirement Income 
     Security Act of 1974 is amended by adding at the end the 
     following:

``Sec. 519. Prohibition on false statement and representations.''.

     SEC. 6602. CLARIFYING DEFINITION.

       Section 24(a)(2) of title 18, United States Code, is 
     amended by inserting ``or section 411, 518, or 511 of the 
     Employee Retirement Income Security Act of 1974,'' after 
     ``1954 of this title''.

     SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM.

       Part C of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg-91 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 2794. UNIFORM FRAUD AND ABUSE REFERRAL FORMAT.

       ``The Secretary shall request the National Association of 
     Insurance Commissioners to develop a model uniform report 
     form for private health insurance issuer seeking to refer 
     suspected fraud and abuse to State insurance departments or 
     other responsible State agencies for investigation. The 
     Secretary shall request that the National Association of 
     Insurance Commissioners develop recommendations for uniform 
     reporting standards for such referrals.''.

     SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND 
                   ABUSE.

       (a) In General.--Part 5 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 (29 U.S.C. 
     1131 et seq.), as amended by section 6601, is further amended 
     by adding at the end the following:

     ``SEC. 520. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND 
                   ABUSE.

       ``The Secretary may, for the purpose of identifying, 
     preventing, or prosecuting fraud and abuse, adopt regulatory 
     standards establishing, or issue an order relating to a 
     specific person establishing, that a person engaged in the 
     business of providing insurance through a multiple employer 
     welfare arrangement described in section 3(40) is subject to 
     the laws of the States in which such person operates which 
     regulate insurance in such State, notwithstanding section 
     514(b)(6) of this Act or the Liability Risk Retention Act of 
     1986, and regardless of whether the law of the State is 
     otherwise preempted under any of such provisions. This 
     section shall not apply to any plan or arrangement that does 
     not fall within the meaning of the term `multiple employer 
     welfare arrangement' under section 3(40)(A).''.
       (b) Conforming Amendment.--The table of sections for part 5 
     of subtitle B of title I of the Employee Retirement Income 
     Security Act of 1974, as amended by section 6601, is further 
     amended by adding at the end the following:

``Sec. 520. Applicability of State law to combat fraud and abuse.''.

     SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE 
                   ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS 
                   AND SUMMARY SEIZURES ORDERS AGAINST PLANS THAT 
                   ARE IN FINANCIALLY HAZARDOUS CONDITION.

       (a) In General.--Part 5 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 (29 U.S.C. 
     1131 et seq.), as amended by section 6604, is further amended 
     by adding at the end the following:

     ``SEC. 521. ADMINISTRATIVE SUMMARY CEASE AND DESIST ORDERS 
                   AND SUMMARY SEIZURE ORDERS AGAINST MULTIPLE 
                   EMPLOYER WELFARE ARRANGEMENTS IN FINANCIALLY 
                   HAZARDOUS CONDITION.

       ``(a) In General.--The Secretary may issue a cease and 
     desist (ex parte) order under this title if it appears to the 
     Secretary that the alleged conduct of a multiple employer 
     welfare arrangement described in section 3(40), other than a 
     plan or arrangement described in subsection (g), is 
     fraudulent, or creates an immediate danger to the public 
     safety or welfare, or is causing or can be reasonably 
     expected to cause significant, imminent, and irreparable 
     public injury.
       ``(b) Hearing.--A person that is adversely affected by the 
     issuance of a cease and desist order under subsection (a) may 
     request a hearing by the Secretary regarding such order. The 
     Secretary may require that a proceeding under this section, 
     including all related information and evidence, be conducted 
     in a confidential manner.
       ``(c) Burden of Proof.--The burden of proof in any hearing 
     conducted under subsection (b) shall be on the party 
     requesting the hearing to show cause why the cease and desist 
     order should be set aside.
       ``(d) Determination.--Based upon the evidence presented at 
     a hearing under subsection (b), the cease and desist order 
     involved may be affirmed, modified, or set aside by the 
     Secretary in whole or in part.
       ``(e) Seizure.--The Secretary may issue a summary seizure 
     order under this title if it appears that a multiple employer 
     welfare arrangement is in a financially hazardous condition.
       ``(f) Regulations.--The Secretary may promulgate such 
     regulations or other guidance as may be necessary or 
     appropriate to carry out this section.
       ``(g) Exception.--This section shall not apply to any plan 
     or arrangement that does not fall

[[Page 4380]]

     within the meaning of the term `multiple employer welfare 
     arrangement' under section 3(40)(A).''.
       (b) Conforming Amendment.--The table of sections for part 5 
     of subtitle B of title I of the Employee Retirement Income 
     Security Act of 1974, as amended by section 6604, is further 
     amended by adding at the end the following:

``Sec. 521. Administrative summary cease and desist orders and summary 
              seizure orders against health plans in financially 
              hazardous condition.''.

     SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR.

       Section 101(g) of the Employee Retirement Income Security 
     Act of 1974 (29 U.S.C. 1021(g)) is amended--
       (1) by striking ``Secretary may'' and inserting ``Secretary 
     shall''; and
       (2) by inserting ``to register with the Secretary prior to 
     operating in a State and may, by regulation, require such 
     multiple employer welfare arrangements'' after ``not group 
     health plans''.

     SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL 
                   COMMUNICATIONS.

       Section 504 of the Employee Retirement Income Security Act 
     of 1974 (29 U.S.C. 1134) is amended by adding at the end the 
     following:
       ``(d) The Secretary may promulgate a regulation that 
     provides an evidentiary privilege for, and provides for the 
     confidentiality of communications between or among, any of 
     the following entities or their agents, consultants, or 
     employees:
       ``(1) A State insurance department.
       ``(2) A State attorney general.
       ``(3) The National Association of Insurance Commissioners.
       ``(4) The Department of Labor.
       ``(5) The Department of the Treasury.
       ``(6) The Department of Justice.
       ``(7) The Department of Health and Human Services.
       ``(8) Any other Federal or State authority that the 
     Secretary determines is appropriate for the purposes of 
     enforcing the provisions of this title.
       ``(e) The privilege established under subsection (d) shall 
     apply to communications related to any investigation, audit, 
     examination, or inquiry conducted or coordinated by any of 
     the agencies. A communication that is privileged under 
     subsection (d) shall not waive any privilege otherwise 
     available to the communicating agency or to any person who 
     provided the information that is communicated.''.

                     Subtitle H--Elder Justice Act

     SEC. 6701. SHORT TITLE OF SUBTITLE.

       This subtitle may be cited as the ``Elder Justice Act of 
     2009''.

     SEC. 6702. DEFINITIONS.

       Except as otherwise specifically provided, any term that is 
     defined in section 2011 of the Social Security Act (as added 
     by section 6703(a)) and is used in this subtitle has the 
     meaning given such term by such section.

     SEC. 6703. ELDER JUSTICE.

       (a) Elder Justice.--
       (1) In general.--Title XX of the Social Security Act (42 
     U.S.C. 1397 et seq.) is amended--
       (A) in the heading, by inserting ``AND ELDER JUSTICE'' 
     after ``SOCIAL SERVICES'';
       (B) by inserting before section 2001 the following:

      ``Subtitle A--Block Grants to States for Social Services'';

     and
       (C) by adding at the end the following:

                      ``Subtitle B--Elder Justice

     ``SEC. 2011. DEFINITIONS.

       ``In this subtitle:
       ``(1) Abuse.--The term `abuse' means the knowing infliction 
     of physical or psychological harm or the knowing deprivation 
     of goods or services that are necessary to meet essential 
     needs or to avoid physical or psychological harm.
       ``(2) Adult protective services.--The term `adult 
     protective services' means such services provided to adults 
     as the Secretary may specify and includes services such as--
       ``(A) receiving reports of adult abuse, neglect, or 
     exploitation;
       ``(B) investigating the reports described in subparagraph 
     (A);
       ``(C) case planning, monitoring, evaluation, and other case 
     work and services; and
       ``(D) providing, arranging for, or facilitating the 
     provision of medical, social service, economic, legal, 
     housing, law enforcement, or other protective, emergency, or 
     support services.
       ``(3) Caregiver.--The term `caregiver' means an individual 
     who has the responsibility for the care of an elder, either 
     voluntarily, by contract, by receipt of payment for care, or 
     as a result of the operation of law, and means a family 
     member or other individual who provides (on behalf of such 
     individual or of a public or private agency, organization, or 
     institution) compensated or uncompensated care to an elder 
     who needs supportive services in any setting.
       ``(4) Direct care.--The term `direct care' means care by an 
     employee or contractor who provides assistance or long-term 
     care services to a recipient.
       ``(5) Elder.--The term `elder' means an individual age 60 
     or older.
       ``(6) Elder justice.--The term `elder justice' means--
       ``(A) from a societal perspective, efforts to--
       ``(i) prevent, detect, treat, intervene in, and prosecute 
     elder abuse, neglect, and exploitation; and
       ``(ii) protect elders with diminished capacity while 
     maximizing their autonomy; and
       ``(B) from an individual perspective, the recognition of an 
     elder's rights, including the right to be free of abuse, 
     neglect, and exploitation.
       ``(7) Eligible entity.--The term `eligible entity' means a 
     State or local government agency, Indian tribe or tribal 
     organization, or any other public or private entity that is 
     engaged in and has expertise in issues relating to elder 
     justice or in a field necessary to promote elder justice 
     efforts.
       ``(8) Exploitation.--The term `exploitation' means the 
     fraudulent or otherwise illegal, unauthorized, or improper 
     act or process of an individual, including a caregiver or 
     fiduciary, that uses the resources of an elder for monetary 
     or personal benefit, profit, or gain, or that results in 
     depriving an elder of rightful access to, or use of, 
     benefits, resources, belongings, or assets.
       ``(9) Fiduciary.--The term `fiduciary'--
       ``(A) means a person or entity with the legal 
     responsibility--
       ``(i) to make decisions on behalf of and for the benefit of 
     another person; and
       ``(ii) to act in good faith and with fairness; and
       ``(B) includes a trustee, a guardian, a conservator, an 
     executor, an agent under a financial power of attorney or 
     health care power of attorney, or a representative payee.
       ``(10) Grant.--The term `grant' includes a contract, 
     cooperative agreement, or other mechanism for providing 
     financial assistance.
       ``(11) Guardianship.--The term `guardianship' means--
       ``(A) the process by which a State court determines that an 
     adult individual lacks capacity to make decisions about self-
     care or property, and appoints another individual or entity 
     known as a guardian, as a conservator, or by a similar term, 
     as a surrogate decisionmaker;
       ``(B) the manner in which the court-appointed surrogate 
     decisionmaker carries out duties to the individual and the 
     court; or
       ``(C) the manner in which the court exercises oversight of 
     the surrogate decisionmaker.
       ``(12) Indian tribe.--
       ``(A) In general.--The term `Indian tribe' has the meaning 
     given such term in section 4 of the Indian Self-Determination 
     and Education Assistance Act (25 U.S.C. 450b).
       ``(B) Inclusion of pueblo and rancheria.--The term `Indian 
     tribe' includes any Pueblo or Rancheria.
       ``(13) Law enforcement.--The term `law enforcement' means 
     the full range of potential responders to elder abuse, 
     neglect, and exploitation including--
       ``(A) police, sheriffs, detectives, public safety officers, 
     and corrections personnel;
       ``(B) prosecutors;
       ``(C) medical examiners;
       ``(D) investigators; and
       ``(E) coroners.
       ``(14) Long-term care.--
       ``(A) In general.--The term `long-term care' means 
     supportive and health services specified by the Secretary for 
     individuals who need assistance because the individuals have 
     a loss of capacity for self-care due to illness, disability, 
     or vulnerability.
       ``(B) Loss of capacity for self-care.--For purposes of 
     subparagraph (A), the term `loss of capacity for self-care' 
     means an inability to engage in 1 or more activities of daily 
     living, including eating, dressing, bathing, management of 
     one's financial affairs, and other activities the Secretary 
     determines appropriate.
       ``(15) Long-term care facility.--The term `long-term care 
     facility' means a residential care provider that arranges 
     for, or directly provides, long-term care.
       ``(16) Neglect.--The term `neglect' means--
       ``(A) the failure of a caregiver or fiduciary to provide 
     the goods or services that are necessary to maintain the 
     health or safety of an elder; or
       ``(B) self-neglect.
       ``(17) Nursing facility.--
       ``(A) In general.--The term `nursing facility' has the 
     meaning given such term under section 1919(a).
       ``(B) Inclusion of skilled nursing facility.--The term 
     `nursing facility' includes a skilled nursing facility (as 
     defined in section 1819(a)).
       ``(18) Self-neglect.--The term `self-neglect' means an 
     adult's inability, due to physical or mental impairment or 
     diminished capacity, to perform essential self-care tasks 
     including--
       ``(A) obtaining essential food, clothing, shelter, and 
     medical care;
       ``(B) obtaining goods and services necessary to maintain 
     physical health, mental health, or general safety; or
       ``(C) managing one's own financial affairs.
       ``(19) Serious bodily injury.--
       ``(A) In general.--The term `serious bodily injury' means 
     an injury--
       ``(i) involving extreme physical pain;
       ``(ii) involving substantial risk of death;
       ``(iii) involving protracted loss or impairment of the 
     function of a bodily member, organ, or mental faculty; or
       ``(iv) requiring medical intervention such as surgery, 
     hospitalization, or physical rehabilitation.
       ``(B) Criminal sexual abuse.--Serious bodily injury shall 
     be considered to have occurred if the conduct causing the 
     injury is conduct described in section 2241 (relating to 
     aggravated sexual abuse) or 2242 (relating to sexual abuse) 
     of title 18, United States Code, or any similar offense under 
     State law.
       ``(20) Social.--The term `social', when used with respect 
     to a service, includes adult protective services.

[[Page 4381]]

       ``(21) State legal assistance developer.--The term `State 
     legal assistance developer' means an individual described in 
     section 731 of the Older Americans Act of 1965.
       ``(22) State long-term care ombudsman.--The term `State 
     Long-Term Care Ombudsman' means the State Long-Term Care 
     Ombudsman described in section 712(a)(2) of the Older 
     Americans Act of 1965.

     ``SEC. 2012. GENERAL PROVISIONS.

       ``(a) Protection of Privacy.--In pursuing activities under 
     this subtitle, the Secretary shall ensure the protection of 
     individual health privacy consistent with the regulations 
     promulgated under section 264(c) of the Health Insurance 
     Portability and Accountability Act of 1996 and applicable 
     State and local privacy regulations.
       ``(b) Rule of Construction.--Nothing in this subtitle shall 
     be construed to interfere with or abridge an elder's right to 
     practice his or her religion through reliance on prayer alone 
     for healing when this choice--
       ``(1) is contemporaneously expressed, either orally or in 
     writing, with respect to a specific illness or injury which 
     the elder has at the time of the decision by an elder who is 
     competent at the time of the decision;
       ``(2) is previously set forth in a living will, health care 
     proxy, or other advance directive document that is validly 
     executed and applied under State law; or
       ``(3) may be unambiguously deduced from the elder's life 
     history.

    ``PART I--NATIONAL COORDINATION OF ELDER JUSTICE ACTIVITIES AND 
                                RESEARCH

 ``Subpart A--Elder Justice Coordinating Council and Advisory Board on 
                 Elder Abuse, Neglect, and Exploitation

     ``SEC. 2021. ELDER JUSTICE COORDINATING COUNCIL.

       ``(a) Establishment.--There is established within the 
     Office of the Secretary an Elder Justice Coordinating Council 
     (in this section referred to as the `Council').
       ``(b) Membership.--
       ``(1) In general.--The Council shall be composed of the 
     following members:
       ``(A) The Secretary (or the Secretary's designee).
       ``(B) The Attorney General (or the Attorney General's 
     designee).
       ``(C) The head of each Federal department or agency or 
     other governmental entity identified by the Chair referred to 
     in subsection (d) as having responsibilities, or 
     administering programs, relating to elder abuse, neglect, and 
     exploitation.
       ``(2) Requirement.--Each member of the Council shall be an 
     officer or employee of the Federal Government.
       ``(c) Vacancies.--Any vacancy in the Council shall not 
     affect its powers, but shall be filled in the same manner as 
     the original appointment was made.
       ``(d) Chair.--The member described in subsection (b)(1)(A) 
     shall be Chair of the Council.
       ``(e) Meetings.--The Council shall meet at least 2 times 
     per year, as determined by the Chair.
       ``(f) Duties.--
       ``(1) In general.--The Council shall make recommendations 
     to the Secretary for the coordination of activities of the 
     Department of Health and Human Services, the Department of 
     Justice, and other relevant Federal, State, local, and 
     private agencies and entities, relating to elder abuse, 
     neglect, and exploitation and other crimes against elders.
       ``(2) Report.--Not later than the date that is 2 years 
     after the date of enactment of the Elder Justice Act of 2009 
     and every 2 years thereafter, the Council shall submit to the 
     Committee on Finance of the Senate and the Committee on Ways 
     and Means and the Committee on Energy and Commerce of the 
     House of Representatives a report that--
       ``(A) describes the activities and accomplishments of, and 
     challenges faced by--
       ``(i) the Council; and
       ``(ii) the entities represented on the Council; and
       ``(B) makes such recommendations for legislation, model 
     laws, or other action as the Council determines to be 
     appropriate.
       ``(g) Powers of the Council.--
       ``(1) Information from federal agencies.--Subject to the 
     requirements of section 2012(a), the Council may secure 
     directly from any Federal department or agency such 
     information as the Council considers necessary to carry out 
     this section. Upon request of the Chair of the Council, the 
     head of such department or agency shall furnish such 
     information to the Council.
       ``(2) Postal services.--The Council may use the United 
     States mails in the same manner and under the same conditions 
     as other departments and agencies of the Federal Government.
       ``(h) Travel Expenses.--The members of the Council shall 
     not receive compensation for the performance of services for 
     the Council. The members shall be allowed travel expenses, 
     including per diem in lieu of subsistence, at rates 
     authorized for employees of agencies under subchapter I of 
     chapter 57 of title 5, United States Code, while away from 
     their homes or regular places of business in the performance 
     of services for the Council. Notwithstanding section 1342 of 
     title 31, United States Code, the Secretary may accept the 
     voluntary and uncompensated services of the members of the 
     Council.
       ``(i) Detail of Government Employees.--Any Federal 
     Government employee may be detailed to the Council without 
     reimbursement, and such detail shall be without interruption 
     or loss of civil service status or privilege.
       ``(j) Status as Permanent Council.--Section 14 of the 
     Federal Advisory Committee Act (5 U.S.C. App.) shall not 
     apply to the Council.
       ``(k) Authorization of Appropriations.--There are 
     authorized to be appropriated such sums as are necessary to 
     carry out this section.

     ``SEC. 2022. ADVISORY BOARD ON ELDER ABUSE, NEGLECT, AND 
                   EXPLOITATION.

       ``(a) Establishment.--There is established a board to be 
     known as the `Advisory Board on Elder Abuse, Neglect, and 
     Exploitation' (in this section referred to as the `Advisory 
     Board') to create short- and long-term multidisciplinary 
     strategic plans for the development of the field of elder 
     justice and to make recommendations to the Elder Justice 
     Coordinating Council established under section 2021.
       ``(b) Composition.--The Advisory Board shall be composed of 
     27 members appointed by the Secretary from among members of 
     the general public who are individuals with experience and 
     expertise in elder abuse, neglect, and exploitation 
     prevention, detection, treatment, intervention, or 
     prosecution.
       ``(c) Solicitation of Nominations.--The Secretary shall 
     publish a notice in the Federal Register soliciting 
     nominations for the appointment of members of the Advisory 
     Board under subsection (b).
       ``(d) Terms.--
       ``(1) In general.--Each member of the Advisory Board shall 
     be appointed for a term of 3 years, except that, of the 
     members first appointed--
       ``(A) 9 shall be appointed for a term of 3 years;
       ``(B) 9 shall be appointed for a term of 2 years; and
       ``(C) 9 shall be appointed for a term of 1 year.
       ``(2) Vacancies.--
       ``(A) In general.--Any vacancy on the Advisory Board shall 
     not affect its powers, but shall be filled in the same manner 
     as the original appointment was made.
       ``(B) Filling unexpired term.--An individual chosen to fill 
     a vacancy shall be appointed for the unexpired term of the 
     member replaced.
       ``(3) Expiration of terms.--The term of any member shall 
     not expire before the date on which the member's successor 
     takes office.
       ``(e) Election of Officers.--The Advisory Board shall elect 
     a Chair and Vice Chair from among its members. The Advisory 
     Board shall elect its initial Chair and Vice Chair at its 
     initial meeting.
       ``(f) Duties.--
       ``(1) Enhance communication on promoting quality of, and 
     preventing abuse, neglect, and exploitation in, long-term 
     care.--The Advisory Board shall develop collaborative and 
     innovative approaches to improve the quality of, including 
     preventing abuse, neglect, and exploitation in, long-term 
     care.
       ``(2) Collaborative efforts to develop consensus around the 
     management of certain quality-related factors.--
       ``(A) In general.--The Advisory Board shall establish 
     multidisciplinary panels to address, and develop consensus 
     on, subjects relating to improving the quality of long-term 
     care. At least 1 such panel shall address, and develop 
     consensus on, methods for managing resident-to-resident abuse 
     in long-term care.
       ``(B) Activities conducted.--The multidisciplinary panels 
     established under subparagraph (A) shall examine relevant 
     research and data, identify best practices with respect to 
     the subject of the panel, determine the best way to carry out 
     those best practices in a practical and feasible manner, and 
     determine an effective manner of distributing information on 
     such subject.
       ``(3) Report.--Not later than the date that is 18 months 
     after the date of enactment of the Elder Justice Act of 2009, 
     and annually thereafter, the Advisory Board shall prepare and 
     submit to the Elder Justice Coordinating Council, the 
     Committee on Finance of the Senate, and the Committee on Ways 
     and Means and the Committee on Energy and Commerce of the 
     House of Representatives a report containing--
       ``(A) information on the status of Federal, State, and 
     local public and private elder justice activities;
       ``(B) recommendations (including recommended priorities) 
     regarding--
       ``(i) elder justice programs, research, training, services, 
     practice, enforcement, and coordination;
       ``(ii) coordination between entities pursuing elder justice 
     efforts and those involved in related areas that may inform 
     or overlap with elder justice efforts, such as activities to 
     combat violence against women and child abuse and neglect; 
     and
       ``(iii) activities relating to adult fiduciary systems, 
     including guardianship and other fiduciary arrangements;
       ``(C) recommendations for specific modifications needed in 
     Federal and State laws (including regulations) or for 
     programs, research, and training to enhance prevention, 
     detection, and treatment (including diagnosis) of, 
     intervention in (including investigation of), and prosecution 
     of elder abuse, neglect, and exploitation;
       ``(D) recommendations on methods for the most effective 
     coordinated national data collection with respect to elder 
     justice, and elder abuse, neglect, and exploitation; and
       ``(E) recommendations for a multidisciplinary strategic 
     plan to guide the effective and efficient development of the 
     field of elder justice.
       ``(g) Powers of the Advisory Board.--
       ``(1) Information from federal agencies.--Subject to the 
     requirements of section 2012(a),

[[Page 4382]]

     the Advisory Board may secure directly from any Federal 
     department or agency such information as the Advisory Board 
     considers necessary to carry out this section. Upon request 
     of the Chair of the Advisory Board, the head of such 
     department or agency shall furnish such information to the 
     Advisory Board.
       ``(2) Sharing of data and reports.--The Advisory Board may 
     request from any entity pursuing elder justice activities 
     under the Elder Justice Act of 2009 or an amendment made by 
     that Act, any data, reports, or recommendations generated in 
     connection with such activities.
       ``(3) Postal services.--The Advisory Board may use the 
     United States mails in the same manner and under the same 
     conditions as other departments and agencies of the Federal 
     Government.
       ``(h) Travel Expenses.--The members of the Advisory Board 
     shall not receive compensation for the performance of 
     services for the Advisory Board. The members shall be allowed 
     travel expenses for up to 4 meetings per year, including per 
     diem in lieu of subsistence, at rates authorized for 
     employees of agencies under subchapter I of chapter 57 of 
     title 5, United States Code, while away from their homes or 
     regular places of business in the performance of services for 
     the Advisory Board. Notwithstanding section 1342 of title 31, 
     United States Code, the Secretary may accept the voluntary 
     and uncompensated services of the members of the Advisory 
     Board.
       ``(i) Detail of Government Employees.--Any Federal 
     Government employee may be detailed to the Advisory Board 
     without reimbursement, and such detail shall be without 
     interruption or loss of civil service status or privilege.
       ``(j) Status as Permanent Advisory Committee.--Section 14 
     of the Federal Advisory Committee Act (5 U.S.C. App.) shall 
     not apply to the advisory board.
       ``(k) Authorization of Appropriations.--There are 
     authorized to be appropriated such sums as are necessary to 
     carry out this section.

     ``SEC. 2023. RESEARCH PROTECTIONS.

       ``(a) Guidelines.--The Secretary shall promulgate 
     guidelines to assist researchers working in the area of elder 
     abuse, neglect, and exploitation, with issues relating to 
     human subject protections.
       ``(b) Definition of Legally Authorized Representative for 
     Application of Regulations.--For purposes of the application 
     of subpart A of part 46 of title 45, Code of Federal 
     Regulations, to research conducted under this subpart, the 
     term `legally authorized representative' means, unless 
     otherwise provided by law, the individual or judicial or 
     other body authorized under the applicable law to consent to 
     medical treatment on behalf of another person.

     ``SEC. 2024. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated to carry out this 
     subpart--
       ``(1) for fiscal year 2011, $6,500,000; and
       ``(2) for each of fiscal years 2012 through 2014, 
     $7,000,000.

  ``Subpart B--Elder Abuse, Neglect, and Exploitation Forensic Centers

     ``SEC. 2031. ESTABLISHMENT AND SUPPORT OF ELDER ABUSE, 
                   NEGLECT, AND EXPLOITATION FORENSIC CENTERS.

       ``(a) In General.--The Secretary, in consultation with the 
     Attorney General, shall make grants to eligible entities to 
     establish and operate stationary and mobile forensic centers, 
     to develop forensic expertise regarding, and provide services 
     relating to, elder abuse, neglect, and exploitation.
       ``(b) Stationary Forensic Centers.--The Secretary shall 
     make 4 of the grants described in subsection (a) to 
     institutions of higher education with demonstrated expertise 
     in forensics or commitment to preventing or treating elder 
     abuse, neglect, or exploitation, to establish and operate 
     stationary forensic centers.
       ``(c) Mobile Centers.--The Secretary shall make 6 of the 
     grants described in subsection (a) to appropriate entities to 
     establish and operate mobile forensic centers.
       ``(d) Authorized Activities.--
       ``(1) Development of forensic markers and methodologies.--
     An eligible entity that receives a grant under this section 
     shall use funds made available through the grant to assist in 
     determining whether abuse, neglect, or exploitation occurred 
     and whether a crime was committed and to conduct research to 
     describe and disseminate information on--
       ``(A) forensic markers that indicate a case in which elder 
     abuse, neglect, or exploitation may have occurred; and
       ``(B) methodologies for determining, in such a case, when 
     and how health care, emergency service, social and protective 
     services, and legal service providers should intervene and 
     when the providers should report the case to law enforcement 
     authorities.
       ``(2) Development of forensic expertise.--An eligible 
     entity that receives a grant under this section shall use 
     funds made available through the grant to develop forensic 
     expertise regarding elder abuse, neglect, and exploitation in 
     order to provide medical and forensic evaluation, therapeutic 
     intervention, victim support and advocacy, case review, and 
     case tracking.
       ``(3) Collection of evidence.--The Secretary, in 
     coordination with the Attorney General, shall use data made 
     available by grant recipients under this section to develop 
     the capacity of geriatric health care professionals and law 
     enforcement to collect forensic evidence, including 
     collecting forensic evidence relating to a potential 
     determination of elder abuse, neglect, or exploitation.
       ``(e) Application.--To be eligible to receive a grant under 
     this section, an entity shall submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(f) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section--
       ``(1) for fiscal year 2011, $4,000,000;
       ``(2) for fiscal year 2012, $6,000,000; and
       ``(3) for each of fiscal years 2013 and 2014, $8,000,000.

              ``PART II--PROGRAMS TO PROMOTE ELDER JUSTICE

     ``SEC. 2041. ENHANCEMENT OF LONG-TERM CARE.

       ``(a) Grants and Incentives for Long-Term Care Staffing.--
       ``(1) In general.--The Secretary shall carry out 
     activities, including activities described in paragraphs (2) 
     and (3), to provide incentives for individuals to train for, 
     seek, and maintain employment providing direct care in long-
     term care.
       ``(2) Specific programs to enhance training, recruitment, 
     and retention of staff.--
       ``(A) Coordination with secretary of labor to recruit and 
     train long-term care staff.--The Secretary shall coordinate 
     activities under this subsection with the Secretary of Labor 
     in order to provide incentives for individuals to train for 
     and seek employment providing direct care in long-term care.
       ``(B) Career ladders and wage or benefit increases to 
     increase staffing in long-term care.--
       ``(i) In general.--The Secretary shall make grants to 
     eligible entities to carry out programs through which the 
     entities--

       ``(I) offer, to employees who provide direct care to 
     residents of an eligible entity or individuals receiving 
     community-based long-term care from an eligible entity, 
     continuing training and varying levels of certification, 
     based on observed clinical care practices and the amount of 
     time the employees spend providing direct care; and
       ``(II) provide, or make arrangements to provide, bonuses or 
     other increased compensation or benefits to employees who 
     achieve certification under such a program.

       ``(ii) Application.--To be eligible to receive a grant 
     under this subparagraph, an eligible entity shall submit an 
     application to the Secretary at such time, in such manner, 
     and containing such information as the Secretary may require 
     (which may include evidence of consultation with the State in 
     which the eligible entity is located with respect to carrying 
     out activities funded under the grant).
       ``(iii) Authority to limit number of applicants.--Nothing 
     in this subparagraph shall be construed as prohibiting the 
     Secretary from limiting the number of applicants for a grant 
     under this subparagraph.
       ``(3) Specific programs to improve management practices.--
       ``(A) In general.--The Secretary shall make grants to 
     eligible entities to enable the entities to provide training 
     and technical assistance.
       ``(B) Authorized activities.--An eligible entity that 
     receives a grant under subparagraph (A) shall use funds made 
     available through the grant to provide training and technical 
     assistance regarding management practices using methods that 
     are demonstrated to promote retention of individuals who 
     provide direct care, such as--
       ``(i) the establishment of standard human resource policies 
     that reward high performance, including policies that provide 
     for improved wages and benefits on the basis of job reviews;
       ``(ii) the establishment of motivational and thoughtful 
     work organization practices;
       ``(iii) the creation of a workplace culture that respects 
     and values caregivers and their needs;
       ``(iv) the promotion of a workplace culture that respects 
     the rights of residents of an eligible entity or individuals 
     receiving community-based long-term care from an eligible 
     entity and results in improved care for the residents or the 
     individuals; and
       ``(v) the establishment of other programs that promote the 
     provision of high quality care, such as a continuing 
     education program that provides additional hours of training, 
     including on-the-job training, for employees who are 
     certified nurse aides.
       ``(C) Application.--To be eligible to receive a grant under 
     this paragraph, an eligible entity shall submit an 
     application to the Secretary at such time, in such manner, 
     and containing such information as the Secretary may require 
     (which may include evidence of consultation with the State in 
     which the eligible entity is located with respect to carrying 
     out activities funded under the grant).
       ``(D) Authority to limit number of applicants.--Nothing in 
     this paragraph shall be construed as prohibiting the 
     Secretary from limiting the number of applicants for a grant 
     under this paragraph.
       ``(4) Accountability measures.--The Secretary shall develop 
     accountability measures to ensure that the activities 
     conducted using funds made available under this subsection 
     benefit individuals who provide direct care and increase the 
     stability of the long-term care workforce.
       ``(5) Definitions.--In this subsection:
       ``(A) Community-based long-term care.--The term `community-
     based long-term care' has the meaning given such term by the 
     Secretary.
       ``(B) Eligible entity.--The term `eligible entity' means 
     the following:
       ``(i) A long-term care facility.
       ``(ii) A community-based long-term care entity (as defined 
     by the Secretary).
       ``(b) Certified EHR Technology Grant Program.--

[[Page 4383]]

       ``(1) Grants authorized.--The Secretary is authorized to 
     make grants to long-term care facilities for the purpose of 
     assisting such entities in offsetting the costs related to 
     purchasing, leasing, developing, and implementing certified 
     EHR technology (as defined in section 1848(o)(4)) designed to 
     improve patient safety and reduce adverse events and health 
     care complications resulting from medication errors.
       ``(2) Use of grant funds.--Funds provided under grants 
     under this subsection may be used for any of the following:
       ``(A) Purchasing, leasing, and installing computer software 
     and hardware, including handheld computer technologies.
       ``(B) Making improvements to existing computer software and 
     hardware.
       ``(C) Making upgrades and other improvements to existing 
     computer software and hardware to enable e-prescribing.
       ``(D) Providing education and training to eligible long-
     term care facility staff on the use of such technology to 
     implement the electronic transmission of prescription and 
     patient information.
       ``(3) Application.--
       ``(A) In general.--To be eligible to receive a grant under 
     this subsection, a long-term care facility shall submit an 
     application to the Secretary at such time, in such manner, 
     and containing such information as the Secretary may require 
     (which may include evidence of consultation with the State in 
     which the long-term care facility is located with respect to 
     carrying out activities funded under the grant).
       ``(B) Authority to limit number of applicants.--Nothing in 
     this subsection shall be construed as prohibiting the 
     Secretary from limiting the number of applicants for a grant 
     under this subsection.
       ``(4) Participation in state health exchanges.--A long-term 
     care facility that receives a grant under this subsection 
     shall, where available, participate in activities conducted 
     by a State or a qualified State-designated entity (as defined 
     in section 3013(f) of the Public Health Service Act) under a 
     grant under section 3013 of the Public Health Service Act to 
     coordinate care and for other purposes determined appropriate 
     by the Secretary.
       ``(5) Accountability measures.--The Secretary shall develop 
     accountability measures to ensure that the activities 
     conducted using funds made available under this subsection 
     help improve patient safety and reduce adverse events and 
     health care complications resulting from medication errors.
       ``(c) Adoption of Standards for Transactions Involving 
     Clinical Data by Long-Term Care Facilities.--
       ``(1) Standards and compatibility.--The Secretary shall 
     adopt electronic standards for the exchange of clinical data 
     by long-term care facilities, including, where available, 
     standards for messaging and nomenclature. Standards adopted 
     by the Secretary under the preceding sentence shall be 
     compatible with standards established under part C of title 
     XI, standards established under subsections (b)(2)(B)(i) and 
     (e)(4) of section 1860D-4, standards adopted under section 
     3004 of the Public Health Service Act, and general health 
     information technology standards.
       ``(2) Electronic submission of data to the secretary.--
       ``(A) In general.--Not later than 10 years after the date 
     of enactment of the Elder Justice Act of 2009, the Secretary 
     shall have procedures in place to accept the optional 
     electronic submission of clinical data by long-term care 
     facilities pursuant to the standards adopted under paragraph 
     (1).
       ``(B) Rule of construction.--Nothing in this subsection 
     shall be construed to require a long-term care facility to 
     submit clinical data electronically to the Secretary.
       ``(3) Regulations.--The Secretary shall promulgate 
     regulations to carry out this subsection. Such regulations 
     shall require a State, as a condition of the receipt of funds 
     under this part, to conduct such data collection and 
     reporting as the Secretary determines are necessary to 
     satisfy the requirements of this subsection.
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section--
       ``(1) for fiscal year 2011, $20,000,000;
       ``(2) for fiscal year 2012, $17,500,000; and
       ``(3) for each of fiscal years 2013 and 2014, $15,000,000.

     ``SEC. 2042. ADULT PROTECTIVE SERVICES FUNCTIONS AND GRANT 
                   PROGRAMS.

       ``(a) Secretarial Responsibilities.--
       ``(1) In general.--The Secretary shall ensure that the 
     Department of Health and Human Services--
       ``(A) provides funding authorized by this part to State and 
     local adult protective services offices that investigate 
     reports of the abuse, neglect, and exploitation of elders;
       ``(B) collects and disseminates data annually relating to 
     the abuse, exploitation, and neglect of elders in 
     coordination with the Department of Justice;
       ``(C) develops and disseminates information on best 
     practices regarding, and provides training on, carrying out 
     adult protective services;
       ``(D) conducts research related to the provision of adult 
     protective services; and
       ``(E) provides technical assistance to States and other 
     entities that provide or fund the provision of adult 
     protective services, including through grants made under 
     subsections (b) and (c).
       ``(2) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     $3,000,000 for fiscal year 2011 and $4,000,000 for each of 
     fiscal years 2012 through 2014.
       ``(b) Grants To Enhance the Provision of Adult Protective 
     Services.--
       ``(1) Establishment.--There is established an adult 
     protective services grant program under which the Secretary 
     shall annually award grants to States in the amounts 
     calculated under paragraph (2) for the purposes of enhancing 
     adult protective services provided by States and local units 
     of government.
       ``(2) Amount of payment.--
       ``(A) In general.--Subject to the availability of 
     appropriations and subparagraphs (B) and (C), the amount paid 
     to a State for a fiscal year under the program under this 
     subsection shall equal the amount appropriated for that year 
     to carry out this subsection multiplied by the percentage of 
     the total number of elders who reside in the United States 
     who reside in that State.
       ``(B) Guaranteed minimum payment amount.--
       ``(i) 50 states.--Subject to clause (ii), if the amount 
     determined under subparagraph (A) for a State for a fiscal 
     year is less than 0.75 percent of the amount appropriated for 
     such year, the Secretary shall increase such determined 
     amount so that the total amount paid under this subsection to 
     the State for the year is equal to 0.75 percent of the amount 
     so appropriated.
       ``(ii) Territories.--In the case of a State other than 1 of 
     the 50 States, clause (i) shall be applied as if each 
     reference to `0.75' were a reference to `0.1'.
       ``(C) Pro rata reductions.--The Secretary shall make such 
     pro rata reductions to the amounts described in subparagraph 
     (A) as are necessary to comply with the requirements of 
     subparagraph (B).
       ``(3) Authorized activities.--
       ``(A) Adult protective services.--Funds made available 
     pursuant to this subsection may only be used by States and 
     local units of government to provide adult protective 
     services and may not be used for any other purpose.
       ``(B) Use by agency.--Each State receiving funds pursuant 
     to this subsection shall provide such funds to the agency or 
     unit of State government having legal responsibility for 
     providing adult protective services within the State.
       ``(C) Supplement not supplant.--Each State or local unit of 
     government shall use funds made available pursuant to this 
     subsection to supplement and not supplant other Federal, 
     State, and local public funds expended to provide adult 
     protective services in the State.
       ``(4) State reports.--Each State receiving funds under this 
     subsection shall submit to the Secretary, at such time and in 
     such manner as the Secretary may require, a report on the 
     number of elders served by the grants awarded under this 
     subsection.
       ``(5) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     $100,000,000 for each of fiscal years 2011 through 2014.
       ``(c) State Demonstration Programs.--
       ``(1) Establishment.--The Secretary shall award grants to 
     States for the purposes of conducting demonstration programs 
     in accordance with paragraph (2).
       ``(2) Demonstration programs.--Funds made available 
     pursuant to this subsection may be used by States and local 
     units of government to conduct demonstration programs that 
     test--
       ``(A) training modules developed for the purpose of 
     detecting or preventing elder abuse;
       ``(B) methods to detect or prevent financial exploitation 
     of elders;
       ``(C) methods to detect elder abuse;
       ``(D) whether training on elder abuse forensics enhances 
     the detection of elder abuse by employees of the State or 
     local unit of government; or
       ``(E) other matters relating to the detection or prevention 
     of elder abuse.
       ``(3) Application.--To be eligible to receive a grant under 
     this subsection, a State shall submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(4) State reports.--Each State that receives funds under 
     this subsection shall submit to the Secretary a report at 
     such time, in such manner, and containing such information as 
     the Secretary may require on the results of the demonstration 
     program conducted by the State using funds made available 
     under this subsection.
       ``(5) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     $25,000,000 for each of fiscal years 2011 through 2014.

     ``SEC. 2043. LONG-TERM CARE OMBUDSMAN PROGRAM GRANTS AND 
                   TRAINING.

       ``(a) Grants To Support the Long-Term Care Ombudsman 
     Program.--
       ``(1) In general.--The Secretary shall make grants to 
     eligible entities with relevant expertise and experience in 
     abuse and neglect in long-term care facilities or long-term 
     care ombudsman programs and responsibilities, for the purpose 
     of--
       ``(A) improving the capacity of State long-term care 
     ombudsman programs to respond to and resolve complaints about 
     abuse and neglect;
       ``(B) conducting pilot programs with State long-term care 
     ombudsman offices or local ombudsman entities; and
       ``(C) providing support for such State long-term care 
     ombudsman programs and such pilot programs (such as through 
     the establishment of a national long-term care ombudsman 
     resource center).
       ``(2) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection--

[[Page 4384]]

       ``(A) for fiscal year 2011, $5,000,000;
       ``(B) for fiscal year 2012, $7,500,000; and
       ``(C) for each of fiscal years 2013 and 2014, $10,000,000.
       ``(b) Ombudsman Training Programs.--
       ``(1) In general.--The Secretary shall establish programs 
     to provide and improve ombudsman training with respect to 
     elder abuse, neglect, and exploitation for national 
     organizations and State long-term care ombudsman programs.
       ``(2) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     for each of fiscal years 2011 through 2014, $10,000,000.

     ``SEC. 2044. PROVISION OF INFORMATION REGARDING, AND 
                   EVALUATIONS OF, ELDER JUSTICE PROGRAMS.

       ``(a) Provision of Information.--To be eligible to receive 
     a grant under this part, an applicant shall agree--
       ``(1) except as provided in paragraph (2), to provide the 
     eligible entity conducting an evaluation under subsection (b) 
     of the activities funded through the grant with such 
     information as the eligible entity may require in order to 
     conduct such evaluation; or
       ``(2) in the case of an applicant for a grant under section 
     2041(b), to provide the Secretary with such information as 
     the Secretary may require to conduct an evaluation or audit 
     under subsection (c).
       ``(b) Use of Eligible Entities To Conduct Evaluations.--
       ``(1) Evaluations required.--Except as provided in 
     paragraph (2), the Secretary shall--
       ``(A) reserve a portion (not less than 2 percent) of the 
     funds appropriated with respect to each program carried out 
     under this part; and
       ``(B) use the funds reserved under subparagraph (A) to 
     provide assistance to eligible entities to conduct 
     evaluations of the activities funded under each program 
     carried out under this part.
       ``(2) Certified ehr technology grant program not 
     included.--The provisions of this subsection shall not apply 
     to the certified EHR technology grant program under section 
     2041(b).
       ``(3) Authorized activities.--A recipient of assistance 
     described in paragraph (1)(B) shall use the funds made 
     available through the assistance to conduct a validated 
     evaluation of the effectiveness of the activities funded 
     under a program carried out under this part.
       ``(4) Applications.--To be eligible to receive assistance 
     under paragraph (1)(B), an entity shall submit an application 
     to the Secretary at such time, in such manner, and containing 
     such information as the Secretary may require, including a 
     proposal for the evaluation.
       ``(5) Reports.--Not later than a date specified by the 
     Secretary, an eligible entity receiving assistance under 
     paragraph (1)(B) shall submit to the Secretary, the Committee 
     on Ways and Means and the Committee on Energy and Commerce of 
     the House of Representatives, and the Committee on Finance of 
     the Senate a report containing the results of the evaluation 
     conducted using such assistance together with such 
     recommendations as the entity determines to be appropriate.
       ``(c) Evaluations and Audits of Certified EHR Technology 
     Grant Program by the Secretary.--
       ``(1) Evaluations.--The Secretary shall conduct an 
     evaluation of the activities funded under the certified EHR 
     technology grant program under section 2041(b). Such 
     evaluation shall include an evaluation of whether the funding 
     provided under the grant is expended only for the purposes 
     for which it is made.
       ``(2) Audits.--The Secretary shall conduct appropriate 
     audits of grants made under section 2041(b).

     ``SEC. 2045. REPORT.

       ``Not later than October 1, 2014, the Secretary shall 
     submit to the Elder Justice Coordinating Council established 
     under section 2021, the Committee on Ways and Means and the 
     Committee on Energy and Commerce of the House of 
     Representatives, and the Committee on Finance of the Senate a 
     report--
       ``(1) compiling, summarizing, and analyzing the information 
     contained in the State reports submitted under subsections 
     (b)(4) and (c)(4) of section 2042; and
       ``(2) containing such recommendations for legislative or 
     administrative action as the Secretary determines to be 
     appropriate.

     ``SEC. 2046. RULE OF CONSTRUCTION.

       ``Nothing in this subtitle shall be construed as--
       ``(1) limiting any cause of action or other relief related 
     to obligations under this subtitle that is available under 
     the law of any State, or political subdivision thereof; or
       ``(2) creating a private cause of action for a violation of 
     this subtitle.''.
       (2) Option for state plan under program for temporary 
     assistance for needy families.--
       (A) In general.--Section 402(a)(1)(B) of the Social 
     Security Act (42 U.S.C. 602(a)(1)(B)) is amended by adding at 
     the end the following new clause:
       ``(v) The document shall indicate whether the State intends 
     to assist individuals to train for, seek, and maintain 
     employment--

       ``(I) providing direct care in a long-term care facility 
     (as such terms are defined under section 2011); or
       ``(II) in other occupations related to elder care 
     determined appropriate by the State for which the State 
     identifies an unmet need for service personnel,

     and, if so, shall include an overview of such assistance.''.
       (B) Effective date.--The amendment made by subparagraph (A) 
     shall take effect on January 1, 2011.
       (b) Protecting Residents of Long-Term Care Facilities.--
       (1) National training institute for surveyors.--
       (A) In general.--The Secretary of Health and Human Services 
     shall enter into a contract with an entity for the purpose of 
     establishing and operating a National Training Institute for 
     Federal and State surveyors. Such Institute shall provide and 
     improve the training of surveyors with respect to 
     investigating allegations of abuse, neglect, and 
     misappropriation of property in programs and long-term care 
     facilities that receive payments under title XVIII or XIX of 
     the Social Security Act.
       (B) Activities carried out by the institute.--The contract 
     entered into under subparagraph (A) shall require the 
     Institute established and operated under such contract to 
     carry out the following activities:
       (i) Assess the extent to which State agencies use 
     specialized surveyors for the investigation of reported 
     allegations of abuse, neglect, and misappropriation of 
     property in such programs and long-term care facilities.
       (ii) Evaluate how the competencies of surveyors may be 
     improved to more effectively investigate reported allegations 
     of such abuse, neglect, and misappropriation of property, and 
     provide feedback to Federal and State agencies on the 
     evaluations conducted.
       (iii) Provide a national program of training, tools, and 
     technical assistance to Federal and State surveyors on 
     investigating reports of such abuse, neglect, and 
     misappropriation of property.
       (iv) Develop and disseminate information on best practices 
     for the investigation of such abuse, neglect, and 
     misappropriation of property.
       (v) Assess the performance of State complaint intake 
     systems, in order to ensure that the intake of complaints 
     occurs 24 hours per day, 7 days a week (including holidays).
       (vi) To the extent approved by the Secretary of Health and 
     Human Services, provide a national 24 hours per day, 7 days a 
     week (including holidays), back-up system to State complaint 
     intake systems in order to ensure optimum national 
     responsiveness to complaints of such abuse, neglect, and 
     misappropriation of property.
       (vii) Analyze and report annually on the following:

       (I) The total number and sources of complaints of such 
     abuse, neglect, and misappropriation of property.
       (II) The extent to which such complaints are referred to 
     law enforcement agencies.
       (III) General results of Federal and State investigations 
     of such complaints.

       (viii) Conduct a national study of the cost to State 
     agencies of conducting complaint investigations of skilled 
     nursing facilities and nursing facilities under sections 1819 
     and 1919, respectively, of the Social Security Act (42 U.S.C. 
     1395i-3; 1396r), and making recommendations to the Secretary 
     of Health and Human Services with respect to options to 
     increase the efficiency and cost-effectiveness of such 
     investigations.
       (C) Authorization.--There are authorized to be appropriated 
     to carry out this paragraph, for the period of fiscal years 
     2011 through 2014, $12,000,000.
       (2) Grants to state survey agencies.--
       (A) In general.--The Secretary of Health and Human Services 
     shall make grants to State agencies that perform surveys of 
     skilled nursing facilities or nursing facilities under 
     sections 1819 or 1919, respectively, of the Social Security 
     Act (42 U.S.C. 1395i-3; 1395r).
       (B) Use of funds.--A grant awarded under subparagraph (A) 
     shall be used for the purpose of designing and implementing 
     complaint investigations systems that--
       (i) promptly prioritize complaints in order to ensure a 
     rapid response to the most serious and urgent complaints;
       (ii) respond to complaints with optimum effectiveness and 
     timeliness; and
       (iii) optimize the collaboration between local authorities, 
     consumers, and providers, including--

       (I) such State agency;
       (II) the State Long-Term Care Ombudsman;
       (III) local law enforcement agencies;
       (IV) advocacy and consumer organizations;
       (V) State aging units;
       (VI) Area Agencies on Aging; and
       (VII) other appropriate entities.

       (C) Authorization.--There are authorized to be appropriated 
     to carry out this paragraph, for each of fiscal years 2011 
     through 2014, $5,000,000.
       (3) Reporting of crimes in federally funded long-term care 
     facilities.--Part A of title XI of the Social Security Act 
     (42 U.S.C. 1301 et seq.), as amended by section 6005, is 
     amended by inserting after section 1150A the following new 
     section:


``reporting to law enforcement of crimes occurring in federally funded 
                       long-term care facilities

       ``Sec. 1150B.  (a) Determination and Notification.--
       ``(1) Determination.--The owner or operator of each long-
     term care facility that receives Federal funds under this Act 
     shall annually determine whether the facility received at 
     least $10,000 in such Federal funds during the preceding 
     year.
       ``(2) Notification.--If the owner or operator determines 
     under paragraph (1) that the facility

[[Page 4385]]

     received at least $10,000 in such Federal funds during the 
     preceding year, such owner or operator shall annually notify 
     each covered individual (as defined in paragraph (3)) of that 
     individual's obligation to comply with the reporting 
     requirements described in subsection (b).
       ``(3) Covered individual defined.--In this section, the 
     term `covered individual' means each individual who is an 
     owner, operator, employee, manager, agent, or contractor of a 
     long-term care facility that is the subject of a 
     determination described in paragraph (1).
       ``(b) Reporting Requirements.--
       ``(1) In general.--Each covered individual shall report to 
     the Secretary and 1 or more law enforcement entities for the 
     political subdivision in which the facility is located any 
     reasonable suspicion of a crime (as defined by the law of the 
     applicable political subdivision) against any individual who 
     is a resident of, or is receiving care from, the facility.
       ``(2) Timing.--If the events that cause the suspicion--
       ``(A) result in serious bodily injury, the individual shall 
     report the suspicion immediately, but not later than 2 hours 
     after forming the suspicion; and
       ``(B) do not result in serious bodily injury, the 
     individual shall report the suspicion not later than 24 hours 
     after forming the suspicion.
       ``(c) Penalties.--
       ``(1) In general.--If a covered individual violates 
     subsection (b)--
       ``(A) the covered individual shall be subject to a civil 
     money penalty of not more than $200,000; and
       ``(B) the Secretary may make a determination in the same 
     proceeding to exclude the covered individual from 
     participation in any Federal health care program (as defined 
     in section 1128B(f)).
       ``(2) Increased harm.--If a covered individual violates 
     subsection (b) and the violation exacerbates the harm to the 
     victim of the crime or results in harm to another 
     individual--
       ``(A) the covered individual shall be subject to a civil 
     money penalty of not more than $300,000; and
       ``(B) the Secretary may make a determination in the same 
     proceeding to exclude the covered individual from 
     participation in any Federal health care program (as defined 
     in section 1128B(f)).
       ``(3) Excluded individual.--During any period for which a 
     covered individual is classified as an excluded individual 
     under paragraph (1)(B) or (2)(B), a long-term care facility 
     that employs such individual shall be ineligible to receive 
     Federal funds under this Act.
       ``(4) Extenuating circumstances.--
       ``(A) In general.--The Secretary may take into account the 
     financial burden on providers with underserved populations in 
     determining any penalty to be imposed under this subsection.
       ``(B) Underserved population defined.--In this paragraph, 
     the term `underserved population' means the population of an 
     area designated by the Secretary as an area with a shortage 
     of elder justice programs or a population group designated by 
     the Secretary as having a shortage of such programs. Such 
     areas or groups designated by the Secretary may include--
       ``(i) areas or groups that are geographically isolated 
     (such as isolated in a rural area);
       ``(ii) racial and ethnic minority populations; and
       ``(iii) populations underserved because of special needs 
     (such as language barriers, disabilities, alien status, or 
     age).
       ``(d) Additional Penalties for Retaliation.--
       ``(1) In general.--A long-term care facility may not--
       ``(A) discharge, demote, suspend, threaten, harass, or deny 
     a promotion or other employment-related benefit to an 
     employee, or in any other manner discriminate against an 
     employee in the terms and conditions of employment because of 
     lawful acts done by the employee; or
       ``(B) file a complaint or a report against a nurse or other 
     employee with the appropriate State professional disciplinary 
     agency because of lawful acts done by the nurse or employee,

     for making a report, causing a report to be made, or for 
     taking steps in furtherance of making a report pursuant to 
     subsection (b)(1).
       ``(2) Penalties for retaliation.--If a long-term care 
     facility violates subparagraph (A) or (B) of paragraph (1) 
     the facility shall be subject to a civil money penalty of not 
     more than $200,000 or the Secretary may classify the entity 
     as an excluded entity for a period of 2 years pursuant to 
     section 1128(b), or both.
       ``(3) Requirement to post notice.--Each long-term care 
     facility shall post conspicuously in an appropriate location 
     a sign (in a form specified by the Secretary) specifying the 
     rights of employees under this section. Such sign shall 
     include a statement that an employee may file a complaint 
     with the Secretary against a long-term care facility that 
     violates the provisions of this subsection and information 
     with respect to the manner of filing such a complaint.
       ``(e) Procedure.--The provisions of section 1128A (other 
     than subsections (a) and (b) and the second sentence of 
     subsection (f)) shall apply to a civil money penalty or 
     exclusion under this section in the same manner as such 
     provisions apply to a penalty or proceeding under section 
     1128A(a).
       ``(f) Definitions.--In this section, the terms `elder 
     justice', `long-term care facility', and `law enforcement' 
     have the meanings given those terms in section 2011.''.
       (c) National Nurse Aide Registry.--
       (1) Definition of nurse aide.--In this subsection, the term 
     ``nurse aide'' has the meaning given that term in sections 
     1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act 
     (42 U.S.C. 1395i-3(b)(5)(F); 1396r(b)(5)(F)).
       (2) Study and report.--
       (A) In general.--The Secretary, in consultation with 
     appropriate government agencies and private sector 
     organizations, shall conduct a study on establishing a 
     national nurse aide registry.
       (B) Areas evaluated.--The study conducted under this 
     subsection shall include an evaluation of--
       (i) who should be included in the registry;
       (ii) how such a registry would comply with Federal and 
     State privacy laws and regulations;
       (iii) how data would be collected for the registry;
       (iv) what entities and individuals would have access to the 
     data collected;
       (v) how the registry would provide appropriate information 
     regarding violations of Federal and State law by individuals 
     included in the registry;
       (vi) how the functions of a national nurse aide registry 
     would be coordinated with the nationwide program for national 
     and State background checks on direct patient access 
     employees of long-term care facilities and providers under 
     section 4301; and
       (vii) how the information included in State nurse aide 
     registries developed and maintained under sections 1819(e)(2) 
     and 1919(e)(2) of the Social Security Act (42 U.S.C. 1395i-
     3(e)(2); 1396r(e)(2)(2)) would be provided as part of a 
     national nurse aide registry.
       (C) Considerations.--In conducting the study and preparing 
     the report required under this subsection, the Secretary 
     shall take into consideration the findings and conclusions of 
     relevant reports and other relevant resources, including the 
     following:
       (i) The Department of Health and Human Services Office of 
     Inspector General Report, Nurse Aide Registries: State 
     Compliance and Practices (February 2005).
       (ii) The General Accounting Office (now known as the 
     Government Accountability Office) Report, Nursing Homes: More 
     Can Be Done to Protect Residents from Abuse (March 2002).
       (iii) The Department of Health and Human Services Office of 
     the Inspector General Report, Nurse Aide Registries: Long-
     Term Care Facility Compliance and Practices (July 2005).
       (iv) The Department of Health and Human Services Health 
     Resources and Services Administration Report, Nursing Aides, 
     Home Health Aides, and Related Health Care Occupations--
     National and Local Workforce Shortages and Associated Data 
     Needs (2004) (in particular with respect to chapter 7 and 
     appendix F).
       (v) The 2001 Report to CMS from the School of Rural Public 
     Health, Texas A&M University, Preventing Abuse and Neglect in 
     Nursing Homes: The Role of Nurse Aide Registries.
       (vi) Information included in State nurse aide registries 
     developed and maintained under sections 1819(e)(2) and 
     1919(e)(2) of the Social Security Act (42 U.S.C. 1395i-
     3(e)(2); 1396r(e)(2)(2)).
       (D) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary shall submit to the 
     Elder Justice Coordinating Council established under section 
     2021 of the Social Security Act, as added by section 1805(a), 
     the Committee on Finance of the Senate, and the Committee on 
     Ways and Means and the Committee on Energy and Commerce of 
     the House of Representatives a report containing the findings 
     and recommendations of the study conducted under this 
     paragraph.
       (E) Funding limitation.--Funding for the study conducted 
     under this subsection shall not exceed $500,000.
       (3) Congressional action.--After receiving the report 
     submitted by the Secretary under paragraph (2)(D), the 
     Committee on Finance of the Senate and the Committee on Ways 
     and Means and the Committee on Energy and Commerce of the 
     House of Representatives shall, as they deem appropriate, 
     take action based on the recommendations contained in the 
     report.
       (4) Authorization of appropriations.--There are authorized 
     to be appropriated such sums as are necessary for the purpose 
     of carrying out this subsection.
       (d) Conforming Amendments.--
       (1) Title xx.--Title XX of the Social Security Act (42 
     U.S.C. 1397 et seq.), as amended by section 6703(a), is 
     amended--
       (A) in the heading of section 2001, by striking ``title'' 
     and inserting ``subtitle''; and
       (B) in subtitle 1, by striking ``this title'' each place it 
     appears and inserting ``this subtitle''.
       (2) Title iv.--Title IV of the Social Security Act (42 
     U.S.C. 601 et seq.) is amended--
       (A) in section 404(d)--
       (i) in paragraphs (1)(A), (2)(A), and (3)(B), by inserting 
     ``subtitle 1 of'' before ``title XX'' each place it appears;
       (ii) in the heading of paragraph (2), by inserting 
     ``subtitle 1 of'' before ``title xx''; and
       (iii) in the heading of paragraph (3)(B), by inserting 
     ``subtitle 1 of'' before ``title xx''; and
       (B) in sections 422(b), 471(a)(4), 472(h)(1), and 
     473(b)(2), by inserting ``subtitle 1 of'' before ``title XX'' 
     each place it appears.
       (3) Title xi.--Title XI of the Social Security Act (42 
     U.S.C. 1301 et seq.) is amended--
       (A) in section 1128(h)(3)--
       (i) by inserting ``subtitle 1 of'' before ``title XX''; and
       (ii) by striking ``such title'' and inserting ``such 
     subtitle''; and
       (B) in section 1128A(i)(1), by inserting ``subtitle 1 of'' 
     before ``title XX''.

[[Page 4386]]



     Subtitle I--Sense of the Senate Regarding Medical Malpractice

     SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MALPRACTICE.

       It is the sense of the Senate that--
       (1) health care reform presents an opportunity to address 
     issues related to medical malpractice and medical liability 
     insurance;
       (2) States should be encouraged to develop and test 
     alternatives to the existing civil litigation system as a way 
     of improving patient safety, reducing medical errors, 
     encouraging the efficient resolution of disputes, increasing 
     the availability of prompt and fair resolution of disputes, 
     and improving access to liability insurance, while preserving 
     an individual's right to seek redress in court; and
       (3) Congress should consider establishing a State 
     demonstration program to evaluate alternatives to the 
     existing civil litigation system with respect to the 
     resolution of medical malpractice claims.

      TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

         Subtitle A--Biologics Price Competition and Innovation

     SEC. 7001. SHORT TITLE.

       (a) In General.--This subtitle may be cited as the 
     ``Biologics Price Competition and Innovation Act of 2009''.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that a biosimilars pathway balancing innovation and consumer 
     interests should be established.

     SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL 
                   PRODUCTS.

       (a) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--Section 351 of the Public Health Service 
     Act (42 U.S.C. 262) is amended--
       (1) in subsection (a)(1)(A), by inserting ``under this 
     subsection or subsection (k)'' after ``biologics license''; 
     and
       (2) by adding at the end the following:
       ``(k) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--
       ``(1) In general.--Any person may submit an application for 
     licensure of a biological product under this subsection.
       ``(2) Content.--
       ``(A) In general.--
       ``(i) Required information.--An application submitted under 
     this subsection shall include information demonstrating 
     that--

       ``(I) the biological product is biosimilar to a reference 
     product based upon data derived from--

       ``(aa) analytical studies that demonstrate that the 
     biological product is highly similar to the reference product 
     notwithstanding minor differences in clinically inactive 
     components;
       ``(bb) animal studies (including the assessment of 
     toxicity); and
       ``(cc) a clinical study or studies (including the 
     assessment of immunogenicity and pharmacokinetics or 
     pharmacodynamics) that are sufficient to demonstrate safety, 
     purity, and potency in 1 or more appropriate conditions of 
     use for which the reference product is licensed and intended 
     to be used and for which licensure is sought for the 
     biological product;

       ``(II) the biological product and reference product utilize 
     the same mechanism or mechanisms of action for the condition 
     or conditions of use prescribed, recommended, or suggested in 
     the proposed labeling, but only to the extent the mechanism 
     or mechanisms of action are known for the reference product;
       ``(III) the condition or conditions of use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     biological product have been previously approved for the 
     reference product;
       ``(IV) the route of administration, the dosage form, and 
     the strength of the biological product are the same as those 
     of the reference product; and
       ``(V) the facility in which the biological product is 
     manufactured, processed, packed, or held meets standards 
     designed to assure that the biological product continues to 
     be safe, pure, and potent.

       ``(ii) Determination by secretary.--The Secretary may 
     determine, in the Secretary's discretion, that an element 
     described in clause (i)(I) is unnecessary in an application 
     submitted under this subsection.
       ``(iii) Additional information.--An application submitted 
     under this subsection--

       ``(I) shall include publicly-available information 
     regarding the Secretary's previous determination that the 
     reference product is safe, pure, and potent; and
       ``(II) may include any additional information in support of 
     the application, including publicly-available information 
     with respect to the reference product or another biological 
     product.

       ``(B) Interchangeability.--An application (or a supplement 
     to an application) submitted under this subsection may 
     include information demonstrating that the biological product 
     meets the standards described in paragraph (4).
       ``(3) Evaluation by secretary.--Upon review of an 
     application (or a supplement to an application) submitted 
     under this subsection, the Secretary shall license the 
     biological product under this subsection if--
       ``(A) the Secretary determines that the information 
     submitted in the application (or the supplement) is 
     sufficient to show that the biological product--
       ``(i) is biosimilar to the reference product; or
       ``(ii) meets the standards described in paragraph (4), and 
     therefore is interchangeable with the reference product; and
       ``(B) the applicant (or other appropriate person) consents 
     to the inspection of the facility that is the subject of the 
     application, in accordance with subsection (c).
       ``(4) Safety standards for determining 
     interchangeability.--Upon review of an application submitted 
     under this subsection or any supplement to such application, 
     the Secretary shall determine the biological product to be 
     interchangeable with the reference product if the Secretary 
     determines that the information submitted in the application 
     (or a supplement to such application) is sufficient to show 
     that--
       ``(A) the biological product--
       ``(i) is biosimilar to the reference product; and
       ``(ii) can be expected to produce the same clinical result 
     as the reference product in any given patient; and
       ``(B) for a biological product that is administered more 
     than once to an individual, the risk in terms of safety or 
     diminished efficacy of alternating or switching between use 
     of the biological product and the reference product is not 
     greater than the risk of using the reference product without 
     such alternation or switch.
       ``(5) General rules.--
       ``(A) One reference product per application.--A biological 
     product, in an application submitted under this subsection, 
     may not be evaluated against more than 1 reference product.
       ``(B) Review.--An application submitted under this 
     subsection shall be reviewed by the division within the Food 
     and Drug Administration that is responsible for the review 
     and approval of the application under which the reference 
     product is licensed.
       ``(C) Risk evaluation and mitigation strategies.--The 
     authority of the Secretary with respect to risk evaluation 
     and mitigation strategies under the Federal Food, Drug, and 
     Cosmetic Act shall apply to biological products licensed 
     under this subsection in the same manner as such authority 
     applies to biological products licensed under subsection (a).
       ``(6) Exclusivity for first interchangeable biological 
     product.--Upon review of an application submitted under this 
     subsection relying on the same reference product for which a 
     prior biological product has received a determination of 
     interchangeability for any condition of use, the Secretary 
     shall not make a determination under paragraph (4) that the 
     second or subsequent biological product is interchangeable 
     for any condition of use until the earlier of--
       ``(A) 1 year after the first commercial marketing of the 
     first interchangeable biosimilar biological product to be 
     approved as interchangeable for that reference product;
       ``(B) 18 months after--
       ``(i) a final court decision on all patents in suit in an 
     action instituted under subsection (l)(6) against the 
     applicant that submitted the application for the first 
     approved interchangeable biosimilar biological product; or
       ``(ii) the dismissal with or without prejudice of an action 
     instituted under subsection (l)(6) against the applicant that 
     submitted the application for the first approved 
     interchangeable biosimilar biological product; or
       ``(C)(i) 42 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has been sued under 
     subsection (l)(6) and such litigation is still ongoing within 
     such 42-month period; or
       ``(ii) 18 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has not been sued 
     under subsection (l)(6).
     For purposes of this paragraph, the term `final court 
     decision' means a final decision of a court from which no 
     appeal (other than a petition to the United States Supreme 
     Court for a writ of certiorari) has been or can be taken.
       ``(7) Exclusivity for reference product.--
       ``(A) Effective date of biosimilar application approval.--
     Approval of an application under this subsection may not be 
     made effective by the Secretary until the date that is 12 
     years after the date on which the reference product was first 
     licensed under subsection (a).
       ``(B) Filing period.--An application under this subsection 
     may not be submitted to the Secretary until the date that is 
     4 years after the date on which the reference product was 
     first licensed under subsection (a).
       ``(C) First licensure.--Subparagraphs (A) and (B) shall not 
     apply to a license for or approval of--
       ``(i) a supplement for the biological product that is the 
     reference product; or
       ``(ii) a subsequent application filed by the same sponsor 
     or manufacturer of the biological product that is the 
     reference product (or a licensor, predecessor in interest, or 
     other related entity) for--

       ``(I) a change (not including a modification to the 
     structure of the biological product) that results in a new 
     indication, route of administration, dosing schedule, dosage 
     form, delivery system, delivery device, or strength; or
       ``(II) a modification to the structure of the biological 
     product that does not result in a change in safety, purity, 
     or potency.

       ``(8) Guidance documents.--
       ``(A) In general.--The Secretary may, after opportunity for 
     public comment, issue guidance in accordance, except as 
     provided in subparagraph (B)(i), with section 701(h) of the 
     Federal Food, Drug, and Cosmetic Act with respect to the 
     licensure of a biological product under this subsection. Any 
     such guidance may be general or specific.
       ``(B) Public comment.--

[[Page 4387]]

       ``(i) In general.--The Secretary shall provide the public 
     an opportunity to comment on any proposed guidance issued 
     under subparagraph (A) before issuing final guidance.
       ``(ii) Input regarding most valuable guidance.--The 
     Secretary shall establish a process through which the public 
     may provide the Secretary with input regarding priorities for 
     issuing guidance.
       ``(C) No requirement for application consideration.--The 
     issuance (or non-issuance) of guidance under subparagraph (A) 
     shall not preclude the review of, or action on, an 
     application submitted under this subsection.
       ``(D) Requirement for product class-specific guidance.--If 
     the Secretary issues product class-specific guidance under 
     subparagraph (A), such guidance shall include a description 
     of--
       ``(i) the criteria that the Secretary will use to determine 
     whether a biological product is highly similar to a reference 
     product in such product class; and
       ``(ii) the criteria, if available, that the Secretary will 
     use to determine whether a biological product meets the 
     standards described in paragraph (4).
       ``(E) Certain product classes.--
       ``(i) Guidance.--The Secretary may indicate in a guidance 
     document that the science and experience, as of the date of 
     such guidance, with respect to a product or product class 
     (not including any recombinant protein) does not allow 
     approval of an application for a license as provided under 
     this subsection for such product or product class.
       ``(ii) Modification or reversal.--The Secretary may issue a 
     subsequent guidance document under subparagraph (A) to modify 
     or reverse a guidance document under clause (i).
       ``(iii) No effect on ability to deny license.--Clause (i) 
     shall not be construed to require the Secretary to approve a 
     product with respect to which the Secretary has not indicated 
     in a guidance document that the science and experience, as 
     described in clause (i), does not allow approval of such an 
     application.
       ``(l) Patents.--
       ``(1) Confidential access to subsection (k) application.--
       ``(A) Application of paragraph.--Unless otherwise agreed to 
     by a person that submits an application under subsection (k) 
     (referred to in this subsection as the `subsection (k) 
     applicant') and the sponsor of the application for the 
     reference product (referred to in this subsection as the 
     `reference product sponsor'), the provisions of this 
     paragraph shall apply to the exchange of information 
     described in this subsection.
       ``(B) In general.--
       ``(i) Provision of confidential information.--When a 
     subsection (k) applicant submits an application under 
     subsection (k), such applicant shall provide to the persons 
     described in clause (ii), subject to the terms of this 
     paragraph, confidential access to the information required to 
     be produced pursuant to paragraph (2) and any other 
     information that the subsection (k) applicant determines, in 
     its sole discretion, to be appropriate (referred to in this 
     subsection as the `confidential information').
       ``(ii) Recipients of information.--The persons described in 
     this clause are the following:

       ``(I) Outside counsel.--One or more attorneys designated by 
     the reference product sponsor who are employees of an entity 
     other than the reference product sponsor (referred to in this 
     paragraph as the `outside counsel'), provided that such 
     attorneys do not engage, formally or informally, in patent 
     prosecution relevant or related to the reference product.
       ``(II) In-house counsel.--One attorney that represents the 
     reference product sponsor who is an employee of the reference 
     product sponsor, provided that such attorney does not engage, 
     formally or informally, in patent prosecution relevant or 
     related to the reference product.

       ``(iii) Patent owner access.--A representative of the owner 
     of a patent exclusively licensed to a reference product 
     sponsor with respect to the reference product and who has 
     retained a right to assert the patent or participate in 
     litigation concerning the patent may be provided the 
     confidential information, provided that the representative 
     informs the reference product sponsor and the subsection (k) 
     applicant of his or her agreement to be subject to the 
     confidentiality provisions set forth in this paragraph, 
     including those under clause (ii).
       ``(C) Limitation on disclosure.--No person that receives 
     confidential information pursuant to subparagraph (B) shall 
     disclose any confidential information to any other person or 
     entity, including the reference product sponsor employees, 
     outside scientific consultants, or other outside counsel 
     retained by the reference product sponsor, without the prior 
     written consent of the subsection (k) applicant, which shall 
     not be unreasonably withheld.
       ``(D) Use of confidential information.--Confidential 
     information shall be used for the sole and exclusive purpose 
     of determining, with respect to each patent assigned to or 
     exclusively licensed by the reference product sponsor, 
     whether a claim of patent infringement could reasonably be 
     asserted if the subsection (k) applicant engaged in the 
     manufacture, use, offering for sale, sale, or importation 
     into the United States of the biological product that is the 
     subject of the application under subsection (k).
       ``(E) Ownership of confidential information.--The 
     confidential information disclosed under this paragraph is, 
     and shall remain, the property of the subsection (k) 
     applicant. By providing the confidential information pursuant 
     to this paragraph, the subsection (k) applicant does not 
     provide the reference product sponsor or the outside counsel 
     any interest in or license to use the confidential 
     information, for purposes other than those specified in 
     subparagraph (D).
       ``(F) Effect of infringement action.--In the event that the 
     reference product sponsor files a patent infringement suit, 
     the use of confidential information shall continue to be 
     governed by the terms of this paragraph until such time as a 
     court enters a protective order regarding the information. 
     Upon entry of such order, the subsection (k) applicant may 
     redesignate confidential information in accordance with the 
     terms of that order. No confidential information shall be 
     included in any publicly-available complaint or other 
     pleading. In the event that the reference product sponsor 
     does not file an infringement action by the date specified in 
     paragraph (6), the reference product sponsor shall return or 
     destroy all confidential information received under this 
     paragraph, provided that if the reference product sponsor 
     opts to destroy such information, it will confirm destruction 
     in writing to the subsection (k) applicant.
       ``(G) Rule of construction.--Nothing in this paragraph 
     shall be construed--
       ``(i) as an admission by the subsection (k) applicant 
     regarding the validity, enforceability, or infringement of 
     any patent; or
       ``(ii) as an agreement or admission by the subsection (k) 
     applicant with respect to the competency, relevance, or 
     materiality of any confidential information.
       ``(H) Effect of violation.--The disclosure of any 
     confidential information in violation of this paragraph shall 
     be deemed to cause the subsection (k) applicant to suffer 
     irreparable harm for which there is no adequate legal remedy 
     and the court shall consider immediate injunctive relief to 
     be an appropriate and necessary remedy for any violation or 
     threatened violation of this paragraph.
       ``(2) Subsection (k) application information.--Not later 
     than 20 days after the Secretary notifies the subsection (k) 
     applicant that the application has been accepted for review, 
     the subsection (k) applicant--
       ``(A) shall provide to the reference product sponsor a copy 
     of the application submitted to the Secretary under 
     subsection (k), and such other information that describes the 
     process or processes used to manufacture the biological 
     product that is the subject of such application; and
       ``(B) may provide to the reference product sponsor 
     additional information requested by or on behalf of the 
     reference product sponsor.
       ``(3) List and description of patents.--
       ``(A) List by reference product sponsor.--Not later than 60 
     days after the receipt of the application and information 
     under paragraph (2), the reference product sponsor shall 
     provide to the subsection (k) applicant--
       ``(i) a list of patents for which the reference product 
     sponsor believes a claim of patent infringement could 
     reasonably be asserted by the reference product sponsor, or 
     by a patent owner that has granted an exclusive license to 
     the reference product sponsor with respect to the reference 
     product, if a person not licensed by the reference product 
     sponsor engaged in the making, using, offering to sell, 
     selling, or importing into the United States of the 
     biological product that is the subject of the subsection (k) 
     application; and
       ``(ii) an identification of the patents on such list that 
     the reference product sponsor would be prepared to license to 
     the subsection (k) applicant.
       ``(B) List and description by subsection (k) applicant.--
     Not later than 60 days after receipt of the list under 
     subparagraph (A), the subsection (k) applicant--
       ``(i) may provide to the reference product sponsor a list 
     of patents to which the subsection (k) applicant believes a 
     claim of patent infringement could reasonably be asserted by 
     the reference product sponsor if a person not licensed by the 
     reference product sponsor engaged in the making, using, 
     offering to sell, selling, or importing into the United 
     States of the biological product that is the subject of the 
     subsection (k) application;
       ``(ii) shall provide to the reference product sponsor, with 
     respect to each patent listed by the reference product 
     sponsor under subparagraph (A) or listed by the subsection 
     (k) applicant under clause (i)--

       ``(I) a detailed statement that describes, on a claim by 
     claim basis, the factual and legal basis of the opinion of 
     the subsection (k) applicant that such patent is invalid, 
     unenforceable, or will not be infringed by the commercial 
     marketing of the biological product that is the subject of 
     the subsection (k) application; or
       ``(II) a statement that the subsection (k) applicant does 
     not intend to begin commercial marketing of the biological 
     product before the date that such patent expires; and

       ``(iii) shall provide to the reference product sponsor a 
     response regarding each patent identified by the reference 
     product sponsor under subparagraph (A)(ii).
       ``(C) Description by reference product sponsor.--Not later 
     than 60 days after receipt of the list and statement under 
     subparagraph (B), the reference product sponsor shall provide 
     to the subsection (k) applicant a detailed statement that 
     describes, with respect to each patent described in 
     subparagraph (B)(ii)(I), on a claim by claim basis, the 
     factual and legal basis of the opinion of the reference 
     product sponsor that such patent will be infringed by the 
     commercial marketing of the biological product that is the 
     subject of the subsection (k) application and a response to 
     the statement concerning validity and enforceability provided 
     under subparagraph (B)(ii)(I).

[[Page 4388]]

       ``(4) Patent resolution negotiations.--
       ``(A) In general.--After receipt by the subsection (k) 
     applicant of the statement under paragraph (3)(C), the 
     reference product sponsor and the subsection (k) applicant 
     shall engage in good faith negotiations to agree on which, if 
     any, patents listed under paragraph (3) by the subsection (k) 
     applicant or the reference product sponsor shall be the 
     subject of an action for patent infringement under paragraph 
     (6).
       ``(B) Failure to reach agreement.--If, within 15 days of 
     beginning negotiations under subparagraph (A), the subsection 
     (k) applicant and the reference product sponsor fail to agree 
     on a final and complete list of which, if any, patents listed 
     under paragraph (3) by the subsection (k) applicant or the 
     reference product sponsor shall be the subject of an action 
     for patent infringement under paragraph (6), the provisions 
     of paragraph (5) shall apply to the parties.
       ``(5) Patent resolution if no agreement.--
       ``(A) Number of patents.--The subsection (k) applicant 
     shall notify the reference product sponsor of the number of 
     patents that such applicant will provide to the reference 
     product sponsor under subparagraph (B)(i)(I).
       ``(B) Exchange of patent lists.--
       ``(i) In general.--On a date agreed to by the subsection 
     (k) applicant and the reference product sponsor, but in no 
     case later than 5 days after the subsection (k) applicant 
     notifies the reference product sponsor under subparagraph 
     (A), the subsection (k) applicant and the reference product 
     sponsor shall simultaneously exchange--

       ``(I) the list of patents that the subsection (k) applicant 
     believes should be the subject of an action for patent 
     infringement under paragraph (6); and
       ``(II) the list of patents, in accordance with clause (ii), 
     that the reference product sponsor believes should be the 
     subject of an action for patent infringement under paragraph 
     (6).

       ``(ii) Number of patents listed by reference product 
     sponsor.--

       ``(I) In general.--Subject to subclause (II), the number of 
     patents listed by the reference product sponsor under clause 
     (i)(II) may not exceed the number of patents listed by the 
     subsection (k) applicant under clause (i)(I).
       ``(II) Exception.--If a subsection (k) applicant does not 
     list any patent under clause (i)(I), the reference product 
     sponsor may list 1 patent under clause (i)(II).

       ``(6) Immediate patent infringement action.--
       ``(A) Action if agreement on patent list.--If the 
     subsection (k) applicant and the reference product sponsor 
     agree on patents as described in paragraph (4), not later 
     than 30 days after such agreement, the reference product 
     sponsor shall bring an action for patent infringement with 
     respect to each such patent.
       ``(B) Action if no agreement on patent list.--If the 
     provisions of paragraph (5) apply to the parties as described 
     in paragraph (4)(B), not later than 30 days after the 
     exchange of lists under paragraph (5)(B), the reference 
     product sponsor shall bring an action for patent infringement 
     with respect to each patent that is included on such lists.
       ``(C) Notification and publication of complaint.--
       ``(i) Notification to secretary.--Not later than 30 days 
     after a complaint is served to a subsection (k) applicant in 
     an action for patent infringement described under this 
     paragraph, the subsection (k) applicant shall provide the 
     Secretary with notice and a copy of such complaint.
       ``(ii) Publication by secretary.--The Secretary shall 
     publish in the Federal Register notice of a complaint 
     received under clause (i).
       ``(7) Newly issued or licensed patents.--In the case of a 
     patent that--
       ``(A) is issued to, or exclusively licensed by, the 
     reference product sponsor after the date that the reference 
     product sponsor provided the list to the subsection (k) 
     applicant under paragraph (3)(A); and
       ``(B) the reference product sponsor reasonably believes 
     that, due to the issuance of such patent, a claim of patent 
     infringement could reasonably be asserted by the reference 
     product sponsor if a person not licensed by the reference 
     product sponsor engaged in the making, using, offering to 
     sell, selling, or importing into the United States of the 
     biological product that is the subject of the subsection (k) 
     application,

     not later than 30 days after such issuance or licensing, the 
     reference product sponsor shall provide to the subsection (k) 
     applicant a supplement to the list provided by the reference 
     product sponsor under paragraph (3)(A) that includes such 
     patent, not later than 30 days after such supplement is 
     provided, the subsection (k) applicant shall provide a 
     statement to the reference product sponsor in accordance with 
     paragraph (3)(B), and such patent shall be subject to 
     paragraph (8).
       ``(8) Notice of commercial marketing and preliminary 
     injunction.--
       ``(A) Notice of commercial marketing.--The subsection (k) 
     applicant shall provide notice to the reference product 
     sponsor not later than 180 days before the date of the first 
     commercial marketing of the biological product licensed under 
     subsection (k).
       ``(B) Preliminary injunction.--After receiving the notice 
     under subparagraph (A) and before such date of the first 
     commercial marketing of such biological product, the 
     reference product sponsor may seek a preliminary injunction 
     prohibiting the subsection (k) applicant from engaging in the 
     commercial manufacture or sale of such biological product 
     until the court decides the issue of patent validity, 
     enforcement, and infringement with respect to any patent that 
     is--
       ``(i) included in the list provided by the reference 
     product sponsor under paragraph (3)(A) or in the list 
     provided by the subsection (k) applicant under paragraph 
     (3)(B); and
       ``(ii) not included, as applicable, on--

       ``(I) the list of patents described in paragraph (4); or
       ``(II) the lists of patents described in paragraph (5)(B).

       ``(C) Reasonable cooperation.--If the reference product 
     sponsor has sought a preliminary injunction under 
     subparagraph (B), the reference product sponsor and the 
     subsection (k) applicant shall reasonably cooperate to 
     expedite such further discovery as is needed in connection 
     with the preliminary injunction motion.
       ``(9) Limitation on declaratory judgment action.--
       ``(A) Subsection (k) application provided.--If a subsection 
     (k) applicant provides the application and information 
     required under paragraph (2)(A), neither the reference 
     product sponsor nor the subsection (k) applicant may, prior 
     to the date notice is received under paragraph (8)(A), bring 
     any action under section 2201 of title 28, United States 
     Code, for a declaration of infringement, validity, or 
     enforceability of any patent that is described in clauses (i) 
     and (ii) of paragraph (8)(B).
       ``(B) Subsequent failure to act by subsection (k) 
     applicant.--If a subsection (k) applicant fails to complete 
     an action required of the subsection (k) applicant under 
     paragraph (3)(B)(ii), paragraph (5), paragraph (6)(C)(i), 
     paragraph (7), or paragraph (8)(A), the reference product 
     sponsor, but not the subsection (k) applicant, may bring an 
     action under section 2201 of title 28, United States Code, 
     for a declaration of infringement, validity, or 
     enforceability of any patent included in the list described 
     in paragraph (3)(A), including as provided under paragraph 
     (7).
       ``(C) Subsection (k) application not provided.--If a 
     subsection (k) applicant fails to provide the application and 
     information required under paragraph (2)(A), the reference 
     product sponsor, but not the subsection (k) applicant, may 
     bring an action under section 2201 of title 28, United States 
     Code, for a declaration of infringement, validity, or 
     enforceability of any patent that claims the biological 
     product or a use of the biological product.''.
       (b) Definitions.--Section 351(i) of the Public Health 
     Service Act (42 U.S.C. 262(i)) is amended--
       (1) by striking ``In this section, the term `biological 
     product' means'' and inserting the following: ``In this 
     section:
       ``(1) The term `biological product' means'';
       (2) in paragraph (1), as so designated, by inserting 
     ``protein (except any chemically synthesized polypeptide),'' 
     after ``allergenic product,''; and
       (3) by adding at the end the following:
       ``(2) The term `biosimilar' or `biosimilarity', in 
     reference to a biological product that is the subject of an 
     application under subsection (k), means--
       ``(A) that the biological product is highly similar to the 
     reference product notwithstanding minor differences in 
     clinically inactive components; and
       ``(B) there are no clinically meaningful differences 
     between the biological product and the reference product in 
     terms of the safety, purity, and potency of the product.
       ``(3) The term `interchangeable' or `interchangeability', 
     in reference to a biological product that is shown to meet 
     the standards described in subsection (k)(4), means that the 
     biological product may be substituted for the reference 
     product without the intervention of the health care provider 
     who prescribed the reference product.
       ``(4) The term `reference product' means the single 
     biological product licensed under subsection (a) against 
     which a biological product is evaluated in an application 
     submitted under subsection (k).''.
       (c) Conforming Amendments Relating to Patents.--
       (1) Patents.--Section 271(e) of title 35, United States 
     Code, is amended--
       (A) in paragraph (2)--
       (i) in subparagraph (A), by striking ``or'' at the end;
       (ii) in subparagraph (B), by adding ``or'' at the end; and
       (iii) by inserting after subparagraph (B) the following:
       ``(C)(i) with respect to a patent that is identified in the 
     list of patents described in section 351(l)(3) of the Public 
     Health Service Act (including as provided under section 
     351(l)(7) of such Act), an application seeking approval of a 
     biological product, or
       ``(ii) if the applicant for the application fails to 
     provide the application and information required under 
     section 351(l)(2)(A) of such Act, an application seeking 
     approval of a biological product for a patent that could be 
     identified pursuant to section 351(l)(3)(A)(i) of such 
     Act,''; and
       (iv) in the matter following subparagraph (C) (as added by 
     clause (iii)), by striking ``or veterinary biological 
     product'' and inserting ``, veterinary biological product, or 
     biological product'';
       (B) in paragraph (4)--
       (i) in subparagraph (B), by--

       (I) striking ``or veterinary biological product'' and 
     inserting ``, veterinary biological product, or biological 
     product''; and

[[Page 4389]]

       (II) striking ``and'' at the end;

       (ii) in subparagraph (C), by--

       (I) striking ``or veterinary biological product'' and 
     inserting ``, veterinary biological product, or biological 
     product''; and
       (II) striking the period and inserting ``, and'';

       (iii) by inserting after subparagraph (C) the following:
       ``(D) the court shall order a permanent injunction 
     prohibiting any infringement of the patent by the biological 
     product involved in the infringement until a date which is 
     not earlier than the date of the expiration of the patent 
     that has been infringed under paragraph (2)(C), provided the 
     patent is the subject of a final court decision, as defined 
     in section 351(k)(6) of the Public Health Service Act, in an 
     action for infringement of the patent under section 351(l)(6) 
     of such Act, and the biological product has not yet been 
     approved because of section 351(k)(7) of such Act.''; and
       (iv) in the matter following subparagraph (D) (as added by 
     clause (iii)), by striking ``and (C)'' and inserting ``(C), 
     and (D)''; and
       (C) by adding at the end the following:
       ``(6)(A) Subparagraph (B) applies, in lieu of paragraph 
     (4), in the case of a patent--
       ``(i) that is identified, as applicable, in the list of 
     patents described in section 351(l)(4) of the Public Health 
     Service Act or the lists of patents described in section 
     351(l)(5)(B) of such Act with respect to a biological 
     product; and
       ``(ii) for which an action for infringement of the patent 
     with respect to the biological product--
       ``(I) was brought after the expiration of the 30-day period 
     described in subparagraph (A) or (B), as applicable, of 
     section 351(l)(6) of such Act; or
       ``(II) was brought before the expiration of the 30-day 
     period described in subclause (I), but which was dismissed 
     without prejudice or was not prosecuted to judgment in good 
     faith.
       ``(B) In an action for infringement of a patent described 
     in subparagraph (A), the sole and exclusive remedy that may 
     be granted by a court, upon a finding that the making, using, 
     offering to sell, selling, or importation into the United 
     States of the biological product that is the subject of the 
     action infringed the patent, shall be a reasonable royalty.
       ``(C) The owner of a patent that should have been included 
     in the list described in section 351(l)(3)(A) of the Public 
     Health Service Act, including as provided under section 
     351(l)(7) of such Act for a biological product, but was not 
     timely included in such list, may not bring an action under 
     this section for infringement of the patent with respect to 
     the biological product.''.
       (2) Conforming amendment under title 28.--Section 2201(b) 
     of title 28, United States Code, is amended by inserting 
     before the period the following: ``, or section 351 of the 
     Public Health Service Act''.
       (d) Conforming Amendments Under the Federal Food, Drug, and 
     Cosmetic Act.--
       (1) Content and review of applications.--Section 
     505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 355(b)(5)(B)) is amended by inserting before the 
     period at the end of the first sentence the following: ``or, 
     with respect to an applicant for approval of a biological 
     product under section 351(k) of the Public Health Service 
     Act, any necessary clinical study or studies''.
       (2) New active ingredient.--Section 505B of the Federal 
     Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended by 
     adding at the end the following:
       ``(n) New Active Ingredient.--
       ``(1) Non-interchangeable biosimilar biological product.--A 
     biological product that is biosimilar to a reference product 
     under section 351 of the Public Health Service Act, and that 
     the Secretary has not determined to meet the standards 
     described in subsection (k)(4) of such section for 
     interchangeability with the reference product, shall be 
     considered to have a new active ingredient under this 
     section.
       ``(2) Interchangeable biosimilar biological product.--A 
     biological product that is interchangeable with a reference 
     product under section 351 of the Public Health Service Act 
     shall not be considered to have a new active ingredient under 
     this section.''.
       (e) Products Previously Approved Under Section 505.--
       (1) Requirement to follow section 351.--Except as provided 
     in paragraph (2), an application for a biological product 
     shall be submitted under section 351 of the Public Health 
     Service Act (42 U.S.C. 262) (as amended by this Act).
       (2) Exception.--An application for a biological product may 
     be submitted under section 505 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355) if--
       (A) such biological product is in a product class for which 
     a biological product in such product class is the subject of 
     an application approved under such section 505 not later than 
     the date of enactment of this Act; and
       (B) such application--
       (i) has been submitted to the Secretary of Health and Human 
     Services (referred to in this subtitle as the ``Secretary'') 
     before the date of enactment of this Act; or
       (ii) is submitted to the Secretary not later than the date 
     that is 10 years after the date of enactment of this Act.
       (3) Limitation.--Notwithstanding paragraph (2), an 
     application for a biological product may not be submitted 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355) if there is another biological product 
     approved under subsection (a) of section 351 of the Public 
     Health Service Act that could be a reference product with 
     respect to such application (within the meaning of such 
     section 351) if such application were submitted under 
     subsection (k) of such section 351.
       (4) Deemed approved under section 351.--An approved 
     application for a biological product under section 505 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 
     deemed to be a license for the biological product under such 
     section 351 on the date that is 10 years after the date of 
     enactment of this Act.
       (5) Definitions.--For purposes of this subsection, the term 
     ``biological product'' has the meaning given such term under 
     section 351 of the Public Health Service Act (42 U.S.C. 262) 
     (as amended by this Act).
       (f) Follow-on Biologics User Fees.--
       (1) Development of user fees for biosimilar biological 
     products.--
       (A) In general.--Beginning not later than October 1, 2010, 
     the Secretary shall develop recommendations to present to 
     Congress with respect to the goals, and plans for meeting the 
     goals, for the process for the review of biosimilar 
     biological product applications submitted under section 
     351(k) of the Public Health Service Act (as added by this 
     Act) for the first 5 fiscal years after fiscal year 2012. In 
     developing such recommendations, the Secretary shall consult 
     with--
       (i) the Committee on Health, Education, Labor, and Pensions 
     of the Senate;
       (ii) the Committee on Energy and Commerce of the House of 
     Representatives;
       (iii) scientific and academic experts;
       (iv) health care professionals;
       (v) representatives of patient and consumer advocacy 
     groups; and
       (vi) the regulated industry.
       (B) Public review of recommendations.--After negotiations 
     with the regulated industry, the Secretary shall--
       (i) present the recommendations developed under 
     subparagraph (A) to the Congressional committees specified in 
     such subparagraph;
       (ii) publish such recommendations in the Federal Register;
       (iii) provide for a period of 30 days for the public to 
     provide written comments on such recommendations;
       (iv) hold a meeting at which the public may present its 
     views on such recommendations; and
       (v) after consideration of such public views and comments, 
     revise such recommendations as necessary.
       (C) Transmittal of recommendations.--Not later than January 
     15, 2012, the Secretary shall transmit to Congress the 
     revised recommendations under subparagraph (B), a summary of 
     the views and comments received under such subparagraph, and 
     any changes made to the recommendations in response to such 
     views and comments.
       (2) Establishment of user fee program.--It is the sense of 
     the Senate that, based on the recommendations transmitted to 
     Congress by the Secretary pursuant to paragraph (1)(C), 
     Congress should authorize a program, effective on October 1, 
     2012, for the collection of user fees relating to the 
     submission of biosimilar biological product applications 
     under section 351(k) of the Public Health Service Act (as 
     added by this Act).
       (3) Transitional provisions for user fees for biosimilar 
     biological products.--
       (A) Application of the prescription drug user fee 
     provisions.--Section 735(1)(B) of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 379g(1)(B)) is amended by striking 
     ``section 351'' and inserting ``subsection (a) or (k) of 
     section 351''.
       (B) Evaluation of costs of reviewing biosimilar biological 
     product applications.--During the period beginning on the 
     date of enactment of this Act and ending on October 1, 2010, 
     the Secretary shall collect and evaluate data regarding the 
     costs of reviewing applications for biological products 
     submitted under section 351(k) of the Public Health Service 
     Act (as added by this Act) during such period.
       (C) Audit.--
       (i) In general.--On the date that is 2 years after first 
     receiving a user fee applicable to an application for a 
     biological product under section 351(k) of the Public Health 
     Service Act (as added by this Act), and on a biennial basis 
     thereafter until October 1, 2013, the Secretary shall perform 
     an audit of the costs of reviewing such applications under 
     such section 351(k). Such an audit shall compare--

       (I) the costs of reviewing such applications under such 
     section 351(k) to the amount of the user fee applicable to 
     such applications; and
       (II)(aa) such ratio determined under subclause (I); to
       (bb) the ratio of the costs of reviewing applications for 
     biological products under section 351(a) of such Act (as 
     amended by this Act) to the amount of the user fee applicable 
     to such applications under such section 351(a).

       (ii) Alteration of user fee.--If the audit performed under 
     clause (i) indicates that the ratios compared under subclause 
     (II) of such clause differ by more than 5 percent, then the 
     Secretary shall alter the user fee applicable to applications 
     submitted under such section 351(k) to more appropriately 
     account for the costs of reviewing such applications.
       (iii) Accounting standards.--The Secretary shall perform an 
     audit under clause (i) in conformance with the accounting 
     principles, standards, and requirements prescribed by the 
     Comptroller General of the United States under section 3511 
     of title 31, United State Code, to ensure the validity of any 
     potential variability.
       (4) Authorization of appropriations.--There is authorized 
     to be appropriated to carry

[[Page 4390]]

     out this subsection such sums as may be necessary for each of 
     fiscal years 2010 through 2012.
       (g) Pediatric Studies of Biological Products.--
       (1) In general.--Section 351 of the Public Health Service 
     Act (42 U.S.C. 262) is amended by adding at the end the 
     following:
       ``(m) Pediatric Studies.--
       ``(1) Application of certain provisions.--The provisions of 
     subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and 
     (q) of section 505A of the Federal Food, Drug, and Cosmetic 
     Act shall apply with respect to the extension of a period 
     under paragraphs (2) and (3) to the same extent and in the 
     same manner as such provisions apply with respect to the 
     extension of a period under subsection (b) or (c) of section 
     505A of the Federal Food, Drug, and Cosmetic Act.
       ``(2) Market exclusivity for new biological products.--If, 
     prior to approval of an application that is submitted under 
     subsection (a), the Secretary determines that information 
     relating to the use of a new biological product in the 
     pediatric population may produce health benefits in that 
     population, the Secretary makes a written request for 
     pediatric studies (which shall include a timeframe for 
     completing such studies), the applicant agrees to the 
     request, such studies are completed using appropriate 
     formulations for each age group for which the study is 
     requested within any such timeframe, and the reports thereof 
     are submitted and accepted in accordance with section 
     505A(d)(3) of the Federal Food, Drug, and Cosmetic Act--
       ``(A) the periods for such biological product referred to 
     in subsection (k)(7) are deemed to be 4 years and 6 months 
     rather than 4 years and 12 years and 6 months rather than 12 
     years; and
       ``(B) if the biological product is designated under section 
     526 for a rare disease or condition, the period for such 
     biological product referred to in section 527(a) is deemed to 
     be 7 years and 6 months rather than 7 years.
       ``(3) Market exclusivity for already-marketed biological 
     products.--If the Secretary determines that information 
     relating to the use of a licensed biological product in the 
     pediatric population may produce health benefits in that 
     population and makes a written request to the holder of an 
     approved application under subsection (a) for pediatric 
     studies (which shall include a timeframe for completing such 
     studies), the holder agrees to the request, such studies are 
     completed using appropriate formulations for each age group 
     for which the study is requested within any such timeframe, 
     and the reports thereof are submitted and accepted in 
     accordance with section 505A(d)(3) of the Federal Food, Drug, 
     and Cosmetic Act--
       ``(A) the periods for such biological product referred to 
     in subsection (k)(7) are deemed to be 4 years and 6 months 
     rather than 4 years and 12 years and 6 months rather than 12 
     years; and
       ``(B) if the biological product is designated under section 
     526 for a rare disease or condition, the period for such 
     biological product referred to in section 527(a) is deemed to 
     be 7 years and 6 months rather than 7 years.
       ``(4) Exception.--The Secretary shall not extend a period 
     referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if 
     the determination under section 505A(d)(3) is made later than 
     9 months prior to the expiration of such period.''.
       (2) Studies regarding pediatric research.--
       (A) Program for pediatric study of drugs.--Subsection 
     (a)(1) of section 409I of the Public Health Service Act (42 
     U.S.C. 284m) is amended by inserting ``, biological 
     products,'' after ``including drugs''.
       (B) Institute of medicine study.--Section 505A(p) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355b(p)) is 
     amended by striking paragraphs (4) and (5) and inserting the 
     following:
       ``(4) review and assess the number and importance of 
     biological products for children that are being tested as a 
     result of the amendments made by the Biologics Price 
     Competition and Innovation Act of 2009 and the importance for 
     children, health care providers, parents, and others of 
     labeling changes made as a result of such testing;
       ``(5) review and assess the number, importance, and 
     prioritization of any biological products that are not being 
     tested for pediatric use; and
       ``(6) offer recommendations for ensuring pediatric testing 
     of biological products, including consideration of any 
     incentives, such as those provided under this section or 
     section 351(m) of the Public Health Service Act.''.
       (h) Orphan Products.--If a reference product, as defined in 
     section 351 of the Public Health Service Act (42 U.S.C. 262) 
     (as amended by this Act) has been designated under section 
     526 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
     360bb) for a rare disease or condition, a biological product 
     seeking approval for such disease or condition under 
     subsection (k) of such section 351 as biosimilar to, or 
     interchangeable with, such reference product may be licensed 
     by the Secretary only after the expiration for such reference 
     product of the later of--
       (1) the 7-year period described in section 527(a) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a)); 
     and
       (2) the 12-year period described in subsection (k)(7) of 
     such section 351.

     SEC. 7003. SAVINGS.

       (a) Determination.--The Secretary of the Treasury, in 
     consultation with the Secretary of Health and Human Services, 
     shall for each fiscal year determine the amount of savings to 
     the Federal Government as a result of the enactment of this 
     subtitle.
       (b) Use.--Notwithstanding any other provision of this 
     subtitle (or an amendment made by this subtitle), the savings 
     to the Federal Government generated as a result of the 
     enactment of this subtitle shall be used for deficit 
     reduction.

  Subtitle B--More Affordable Medicines for Children and Underserved 
                              Communities

     SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM.

       (a) Expansion of Covered Entities Receiving Discounted 
     Prices.--Section 340B(a)(4) of the Public Health Service Act 
     (42 U.S.C. 256b(a)(4)) is amended by adding at the end the 
     following:
       ``(M) A children's hospital excluded from the Medicare 
     prospective payment system pursuant to section 
     1886(d)(1)(B)(iii) of the Social Security Act, or a free-
     standing cancer hospital excluded from the Medicare 
     prospective payment system pursuant to section 
     1886(d)(1)(B)(v) of the Social Security Act, that would meet 
     the requirements of subparagraph (L), including the 
     disproportionate share adjustment percentage requirement 
     under clause (ii) of such subparagraph, if the hospital were 
     a subsection (d) hospital as defined by section 1886(d)(1)(B) 
     of the Social Security Act.
       ``(N) An entity that is a critical access hospital (as 
     determined under section 1820(c)(2) of the Social Security 
     Act), and that meets the requirements of subparagraph (L)(i).
       ``(O) An entity that is a rural referral center, as defined 
     by section 1886(d)(5)(C)(i) of the Social Security Act, or a 
     sole community hospital, as defined by section 
     1886(d)(5)(C)(iii) of such Act, and that both meets the 
     requirements of subparagraph (L)(i) and has a 
     disproportionate share adjustment percentage equal to or 
     greater than 8 percent.''.
       (b) Extension of Discount to Inpatient Drugs.--Section 340B 
     of the Public Health Service Act (42 U.S.C. 256b) is 
     amended--
       (1) in paragraphs (2), (5), (7), and (9) of subsection (a), 
     by striking ``outpatient'' each place it appears; and
       (2) in subsection (b)--
       (A) by striking ``Other Definition'' and all that follows 
     through ``In this section'' and inserting the following: 
     ``Other Definitions.--
       ``(1) In general.--In this section''; and
       (B) by adding at the end the following new paragraph:
       ``(2) Covered drug.--In this section, the term `covered 
     drug'--
       ``(A) means a covered outpatient drug (as defined in 
     section 1927(k)(2) of the Social Security Act); and
       ``(B) includes, notwithstanding paragraph (3)(A) of section 
     1927(k) of such Act, a drug used in connection with an 
     inpatient or outpatient service provided by a hospital 
     described in subparagraph (L), (M), (N), or (O) of subsection 
     (a)(4) that is enrolled to participate in the drug discount 
     program under this section.''.
       (c) Prohibition on Group Purchasing Arrangements.--Section 
     340B(a) of the Public Health Service Act (42 U.S.C. 256b(a)) 
     is amended--
       (1) in paragraph (4)(L)--
       (A) in clause (i), by adding ``and'' at the end;
       (B) in clause (ii), by striking ``; and'' and inserting a 
     period; and
       (C) by striking clause (iii); and
       (2) in paragraph (5), as amended by subsection (b)--
       (A) by redesignating subparagraphs (C) and (D) as 
     subparagraphs (D) and (E); respectively; and
       (B) by inserting after subparagraph (B), the following:
       ``(C) Prohibition on group purchasing arrangements.--
       ``(i) In general.--A hospital described in subparagraph 
     (L), (M), (N), or (O) of paragraph (4) shall not obtain 
     covered outpatient drugs through a group purchasing 
     organization or other group purchasing arrangement, except as 
     permitted or provided for pursuant to clauses (ii) or (iii).
       ``(ii) Inpatient drugs.--Clause (i) shall not apply to 
     drugs purchased for inpatient use.
       ``(iii) Exceptions.--The Secretary shall establish 
     reasonable exceptions to clause (i)--

       ``(I) with respect to a covered outpatient drug that is 
     unavailable to be purchased through the program under this 
     section due to a drug shortage problem, manufacturer 
     noncompliance, or any other circumstance beyond the 
     hospital's control;
       ``(II) to facilitate generic substitution when a generic 
     covered outpatient drug is available at a lower price; or
       ``(III) to reduce in other ways the administrative burdens 
     of managing both inventories of drugs subject to this section 
     and inventories of drugs that are not subject to this 
     section, so long as the exceptions do not create a duplicate 
     discount problem in violation of subparagraph (A) or a 
     diversion problem in violation of subparagraph (B).

       ``(iv) Purchasing arrangements for inpatient drugs.--The 
     Secretary shall ensure that a hospital described in 
     subparagraph (L), (M), (N), or (O) of subsection (a)(4) that 
     is enrolled to participate in the drug discount program under 
     this section shall have multiple options for purchasing 
     covered drugs for inpatients, including by utilizing a group 
     purchasing organization or other group purchasing 
     arrangement, establishing and utilizing its own group 
     purchasing program, purchasing directly from a manufacturer, 
     and any other purchasing arrangements that the Secretary 
     determines is appropriate to ensure access to drug discount 
     pricing under this section for inpatient drugs taking into 
     account the particular needs of small and rural hospitals.''.
       (d) Medicaid Credits on Inpatient Drugs.--Section 340B of 
     the Public Health Service Act (42

[[Page 4391]]

     U.S.C. 256b) is amended by striking subsection (c) and 
     inserting the following:
       ``(c) Medicaid Credit.--Not later than 90 days after the 
     date of filing of the hospital's most recently filed Medicare 
     cost report, the hospital shall issue a credit as determined 
     by the Secretary to the State Medicaid program for inpatient 
     covered drugs provided to Medicaid recipients.''.
       (e) Effective Dates.--
       (1) In general.--The amendments made by this section and 
     section 7102 shall take effect on January 1, 2010, and shall 
     apply to drugs purchased on or after January 1, 2010.
       (2) Effectiveness.--The amendments made by this section and 
     section 7102 shall be effective and shall be taken into 
     account in determining whether a manufacturer is deemed to 
     meet the requirements of section 340B(a) of the Public Health 
     Service Act (42 U.S.C. 256b(a)), notwithstanding any other 
     provision of law.

     SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.

       (a) Integrity Improvements.--Subsection (d) of section 340B 
     of the Public Health Service Act (42 U.S.C. 256b) is amended 
     to read as follows:
       ``(d) Improvements in Program Integrity.--
       ``(1) Manufacturer compliance.--
       ``(A) In general.--From amounts appropriated under 
     paragraph (4), the Secretary shall provide for improvements 
     in compliance by manufacturers with the requirements of this 
     section in order to prevent overcharges and other violations 
     of the discounted pricing requirements specified in this 
     section.
       ``(B) Improvements.--The improvements described in 
     subparagraph (A) shall include the following:
       ``(i) The development of a system to enable the Secretary 
     to verify the accuracy of ceiling prices calculated by 
     manufacturers under subsection (a)(1) and charged to covered 
     entities, which shall include the following:

       ``(I) Developing and publishing through an appropriate 
     policy or regulatory issuance, precisely defined standards 
     and methodology for the calculation of ceiling prices under 
     such subsection.
       ``(II) Comparing regularly the ceiling prices calculated by 
     the Secretary with the quarterly pricing data that is 
     reported by manufacturers to the Secretary.
       ``(III) Performing spot checks of sales transactions by 
     covered entities.
       ``(IV) Inquiring into the cause of any pricing 
     discrepancies that may be identified and either taking, or 
     requiring manufacturers to take, such corrective action as is 
     appropriate in response to such price discrepancies.

       ``(ii) The establishment of procedures for manufacturers to 
     issue refunds to covered entities in the event that there is 
     an overcharge by the manufacturers, including the following:

       ``(I) Providing the Secretary with an explanation of why 
     and how the overcharge occurred, how the refunds will be 
     calculated, and to whom the refunds will be issued.
       ``(II) Oversight by the Secretary to ensure that the 
     refunds are issued accurately and within a reasonable period 
     of time, both in routine instances of retroactive adjustment 
     to relevant pricing data and exceptional circumstances such 
     as erroneous or intentional overcharging for covered drugs.

       ``(iii) The provision of access through the Internet 
     website of the Department of Health and Human Services to the 
     applicable ceiling prices for covered drugs as calculated and 
     verified by the Secretary in accordance with this section, in 
     a manner (such as through the use of password protection) 
     that limits such access to covered entities and adequately 
     assures security and protection of privileged pricing data 
     from unauthorized re-disclosure.
       ``(iv) The development of a mechanism by which--

       ``(I) rebates and other discounts provided by manufacturers 
     to other purchasers subsequent to the sale of covered drugs 
     to covered entities are reported to the Secretary; and
       ``(II) appropriate credits and refunds are issued to 
     covered entities if such discounts or rebates have the effect 
     of lowering the applicable ceiling price for the relevant 
     quarter for the drugs involved.

       ``(v) Selective auditing of manufacturers and wholesalers 
     to ensure the integrity of the drug discount program under 
     this section.
       ``(vi) The imposition of sanctions in the form of civil 
     monetary penalties, which--

       ``(I) shall be assessed according to standards established 
     in regulations to be promulgated by the Secretary not later 
     than 180 days after the date of enactment of the Patient 
     Protection and Affordable Care Act;
       ``(II) shall not exceed $5,000 for each instance of 
     overcharging a covered entity that may have occurred; and
       ``(III) shall apply to any manufacturer with an agreement 
     under this section that knowingly and intentionally charges a 
     covered entity a price for purchase of a drug that exceeds 
     the maximum applicable price under subsection (a)(1).

       ``(2) Covered entity compliance.--
       ``(A) In general.--From amounts appropriated under 
     paragraph (4), the Secretary shall provide for improvements 
     in compliance by covered entities with the requirements of 
     this section in order to prevent diversion and violations of 
     the duplicate discount provision and other requirements 
     specified under subsection (a)(5).
       ``(B) Improvements.--The improvements described in 
     subparagraph (A) shall include the following:
       ``(i) The development of procedures to enable and require 
     covered entities to regularly update (at least annually) the 
     information on the Internet website of the Department of 
     Health and Human Services relating to this section.
       ``(ii) The development of a system for the Secretary to 
     verify the accuracy of information regarding covered entities 
     that is listed on the website described in clause (i).
       ``(iii) The development of more detailed guidance 
     describing methodologies and options available to covered 
     entities for billing covered drugs to State Medicaid agencies 
     in a manner that avoids duplicate discounts pursuant to 
     subsection (a)(5)(A).
       ``(iv) The establishment of a single, universal, and 
     standardized identification system by which each covered 
     entity site can be identified by manufacturers, distributors, 
     covered entities, and the Secretary for purposes of 
     facilitating the ordering, purchasing, and delivery of 
     covered drugs under this section, including the processing of 
     chargebacks for such drugs.
       ``(v) The imposition of sanctions, in appropriate cases as 
     determined by the Secretary, additional to those to which 
     covered entities are subject under subsection (a)(5)(E), 
     through one or more of the following actions:

       ``(I) Where a covered entity knowingly and intentionally 
     violates subsection (a)(5)(B), the covered entity shall be 
     required to pay a monetary penalty to a manufacturer or 
     manufacturers in the form of interest on sums for which the 
     covered entity is found liable under subsection (a)(5)(E), 
     such interest to be compounded monthly and equal to the 
     current short term interest rate as determined by the Federal 
     Reserve for the time period for which the covered entity is 
     liable.
       ``(II) Where the Secretary determines a violation of 
     subsection (a)(5)(B) was systematic and egregious as well as 
     knowing and intentional, removing the covered entity from the 
     drug discount program under this section and disqualifying 
     the entity from re-entry into such program for a reasonable 
     period of time to be determined by the Secretary.
       ``(III) Referring matters to appropriate Federal 
     authorities within the Food and Drug Administration, the 
     Office of Inspector General of Department of Health and Human 
     Services, or other Federal agencies for consideration of 
     appropriate action under other Federal statutes, such as the 
     Prescription Drug Marketing Act (21 U.S.C. 353).

       ``(3) Administrative dispute resolution process.--
       ``(A) In general.--Not later than 180 days after the date 
     of enactment of the Patient Protection and Affordable Care 
     Act, the Secretary shall promulgate regulations to establish 
     and implement an administrative process for the resolution of 
     claims by covered entities that they have been overcharged 
     for drugs purchased under this section, and claims by 
     manufacturers, after the conduct of audits as authorized by 
     subsection (a)(5)(D), of violations of subsections (a)(5)(A) 
     or (a)(5)(B), including appropriate procedures for the 
     provision of remedies and enforcement of determinations made 
     pursuant to such process through mechanisms and sanctions 
     described in paragraphs (1)(B) and (2)(B).
       ``(B) Deadlines and procedures.--Regulations promulgated by 
     the Secretary under subparagraph (A) shall--
       ``(i) designate or establish a decision-making official or 
     decision-making body within the Department of Health and 
     Human Services to be responsible for reviewing and finally 
     resolving claims by covered entities that they have been 
     charged prices for covered drugs in excess of the ceiling 
     price described in subsection (a)(1), and claims by 
     manufacturers that violations of subsection (a)(5)(A) or 
     (a)(5)(B) have occurred;
       ``(ii) establish such deadlines and procedures as may be 
     necessary to ensure that claims shall be resolved fairly, 
     efficiently, and expeditiously;
       ``(iii) establish procedures by which a covered entity may 
     discover and obtain such information and documents from 
     manufacturers and third parties as may be relevant to 
     demonstrate the merits of a claim that charges for a 
     manufacturer's product have exceeded the applicable ceiling 
     price under this section, and may submit such documents and 
     information to the administrative official or body 
     responsible for adjudicating such claim;
       ``(iv) require that a manufacturer conduct an audit of a 
     covered entity pursuant to subsection (a)(5)(D) as a 
     prerequisite to initiating administrative dispute resolution 
     proceedings against a covered entity;
       ``(v) permit the official or body designated under clause 
     (i), at the request of a manufacturer or manufacturers, to 
     consolidate claims brought by more than one manufacturer 
     against the same covered entity where, in the judgment of 
     such official or body, consolidation is appropriate and 
     consistent with the goals of fairness and economy of 
     resources; and
       ``(vi) include provisions and procedures to permit multiple 
     covered entities to jointly assert claims of overcharges by 
     the same manufacturer for the same drug or drugs in one 
     administrative proceeding, and permit such claims to be 
     asserted on behalf of covered entities by associations or 
     organizations representing the interests of such covered 
     entities and of which the covered entities are members.
       ``(C) Finality of administrative resolution.--The 
     administrative resolution of a claim or claims under the 
     regulations promulgated under subparagraph (A) shall be a 
     final agency decision and shall be binding upon the parties 
     involved, unless invalidated by an order of a court of 
     competent jurisdiction.
       ``(4) Authorization of appropriations.--There are 
     authorized to be appropriated to carry

[[Page 4392]]

     out this subsection, such sums as may be necessary for fiscal 
     year 2010 and each succeeding fiscal year.''.
       (b) Conforming Amendments.--Section 340B(a) of the Public 
     Health Service Act (42 U.S.C. 256b(a)) is amended--
       (1) in subsection (a)(1), by adding at the end the 
     following: ``Each such agreement shall require that the 
     manufacturer furnish the Secretary with reports, on a 
     quarterly basis, of the price for each covered drug subject 
     to the agreement that, according to the manufacturer, 
     represents the maximum price that covered entities may 
     permissibly be required to pay for the drug (referred to in 
     this section as the `ceiling price'), and shall require that 
     the manufacturer offer each covered entity covered drugs for 
     purchase at or below the applicable ceiling price if such 
     drug is made available to any other purchaser at any 
     price.''; and
       (2) in the first sentence of subsection (a)(5)(E), as 
     redesignated by section 7101(c), by inserting ``after audit 
     as described in subparagraph (D) and'' after ``finds,''.

     SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING THE 
                   340B PROGRAM.

       (a) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Comptroller General of the United 
     States shall submit to Congress a report that examines 
     whether those individuals served by the covered entities 
     under the program under section 340B of the Public Health 
     Service Act (42 U.S.C. 256b) (referred to in this section as 
     the ``340B program'') are receiving optimal health care 
     services.
       (b) Recommendations.--The report under subsection (a) shall 
     include recommendations on the following:
       (1) Whether the 340B program should be expanded since it is 
     anticipated that the 47,000,000 individuals who are uninsured 
     as of the date of enactment of this Act will have health care 
     coverage once this Act is implemented.
       (2) Whether mandatory sales of certain products by the 340B 
     program could hinder patients access to those therapies 
     through any provider.
       (3) Whether income from the 340B program is being used by 
     the covered entities under the program to further the program 
     objectives.

                         TITLE VIII--CLASS ACT

     SEC. 8001. SHORT TITLE OF TITLE.

       This title may be cited as the ``Community Living 
     Assistance Services and Supports Act'' or the ``CLASS Act''.

     SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE 
                   PROGRAM FOR PURCHASING COMMUNITY LIVING 
                   ASSISTANCE SERVICES AND SUPPORT.

       (a) Establishment of CLASS Program.--
       (1) In general.--The Public Health Service Act (42 U.S.C. 
     201 et seq.), as amended by section 4302(a), is amended by 
     adding at the end the following:

    ``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

     ``SEC. 3201. PURPOSE.

       ``The purpose of this title is to establish a national 
     voluntary insurance program for purchasing community living 
     assistance services and supports in order to--
       ``(1) provide individuals with functional limitations with 
     tools that will allow them to maintain their personal and 
     financial independence and live in the community through a 
     new financing strategy for community living assistance 
     services and supports;
       ``(2) establish an infrastructure that will help address 
     the Nation's community living assistance services and 
     supports needs;
       ``(3) alleviate burdens on family caregivers; and
       ``(4) address institutional bias by providing a financing 
     mechanism that supports personal choice and independence to 
     live in the community.

     ``SEC. 3202. DEFINITIONS.

       ``In this title:
       ``(1) Active enrollee.--The term `active enrollee' means an 
     individual who is enrolled in the CLASS program in accordance 
     with section 3204 and who has paid any premiums due to 
     maintain such enrollment.
       ``(2) Actively employed.--The term `actively employed' 
     means an individual who--
       ``(A) is reporting for work at the individual's usual place 
     of employment or at another location to which the individual 
     is required to travel because of the individual's employment 
     (or in the case of an individual who is a member of the 
     uniformed services, is on active duty and is physically able 
     to perform the duties of the individual's position); and
       ``(B) is able to perform all the usual and customary duties 
     of the individual's employment on the individual's regular 
     work schedule.
       ``(3) Activities of daily living.--The term `activities of 
     daily living' means each of the following activities 
     specified in section 7702B(c)(2)(B) of the Internal Revenue 
     Code of 1986:
       ``(A) Eating.
       ``(B) Toileting.
       ``(C) Transferring.
       ``(D) Bathing.
       ``(E) Dressing.
       ``(F) Continence.
       ``(4) CLASS program.--The term `CLASS program' means the 
     program established under this title.
       ``(5) Eligibility assessment system.--The term `Eligibility 
     Assessment System' means the entity established by the 
     Secretary under section 3205(a)(2) to make functional 
     eligibility determinations for the CLASS program.
       ``(6) Eligible beneficiary.--
       ``(A) In general.--The term `eligible beneficiary' means 
     any individual who is an active enrollee in the CLASS program 
     and, as of the date described in subparagraph (B)--
       ``(i) has paid premiums for enrollment in such program for 
     at least 60 months;
       ``(ii) has earned, with respect to at least 3 calendar 
     years that occur during the first 60 months for which the 
     individual has paid premiums for enrollment in the program, 
     at least an amount equal to the amount of wages and self-
     employment income which an individual must have in order to 
     be credited with a quarter of coverage under section 213(d) 
     of the Social Security Act for the year; and
       ``(iii) has paid premiums for enrollment in such program 
     for at least 24 consecutive months, if a lapse in premium 
     payments of more than 3 months has occurred during the period 
     that begins on the date of the individual's enrollment and 
     ends on the date of such determination.
       ``(B) Date described.--For purposes of subparagraph (A), 
     the date described in this subparagraph is the date on which 
     the individual is determined to have a functional limitation 
     described in section 3203(a)(1)(C) that is expected to last 
     for a continuous period of more than 90 days.
       ``(C) Regulations.--The Secretary shall promulgate 
     regulations specifying exceptions to the minimum earnings 
     requirements under subparagraph (A)(ii) for purposes of being 
     considered an eligible beneficiary for certain populations.
       ``(7) Hospital; nursing facility; intermediate care 
     facility for the mentally retarded; institution for mental 
     diseases.--The terms `hospital', `nursing facility', 
     `intermediate care facility for the mentally retarded', and 
     `institution for mental diseases' have the meanings given 
     such terms for purposes of Medicaid.
       ``(8) CLASS independence advisory council.--The term `CLASS 
     Independence Advisory Council' or `Council' means the 
     Advisory Council established under section 3207 to advise the 
     Secretary.
       ``(9) CLASS independence benefit plan.--The term `CLASS 
     Independence Benefit Plan' means the benefit plan developed 
     and designated by the Secretary in accordance with section 
     3203.
       ``(10) CLASS independence fund.--The term `CLASS 
     Independence Fund' or `Fund' means the fund established under 
     section 3206.
       ``(11) Medicaid.--The term `Medicaid' means the program 
     established under title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).
       ``(12) Poverty line.--The term `poverty line' has the 
     meaning given that term in section 2110(c)(5) of the Social 
     Security Act (42 U.S.C. 1397jj(c)(5)).
       ``(13) Protection and advocacy system.--The term 
     `Protection and Advocacy System' means the system for each 
     State established under section 143 of the Developmental 
     Disabilities Assistance and Bill of Rights Act of 2000 (42 
     U.S.C. 15043).

     ``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.

       ``(a) Process for Development.--
       ``(1) In general.--The Secretary, in consultation with 
     appropriate actuaries and other experts, shall develop at 
     least 3 actuarially sound benefit plans as alternatives for 
     consideration for designation by the Secretary as the CLASS 
     Independence Benefit Plan under which eligible beneficiaries 
     shall receive benefits under this title. Each of the plan 
     alternatives developed shall be designed to provide eligible 
     beneficiaries with the benefits described in section 3205 
     consistent with the following requirements:
       ``(A) Premiums.--
       ``(i) In general.--Beginning with the first year of the 
     CLASS program, and for each year thereafter, subject to 
     clauses (ii) and (iii), the Secretary shall establish all 
     premiums to be paid by enrollees for the year based on an 
     actuarial analysis of the 75-year costs of the program that 
     ensures solvency throughout such 75-year period.
       ``(ii) Nominal premium for poorest individuals and full-
     time students.--

       ``(I) In general.--The monthly premium for enrollment in 
     the CLASS program shall not exceed the applicable dollar 
     amount per month determined under subclause (II) for--

       ``(aa) any individual whose income does not exceed the 
     poverty line; and
       ``(bb) any individual who has not attained age 22, and is 
     actively employed during any period in which the individual 
     is a full-time student (as determined by the Secretary).

       ``(II) Applicable dollar amount.--The applicable dollar 
     amount described in this subclause is the amount equal to $5, 
     increased by the percentage increase in the consumer price 
     index for all urban consumers (U.S. city average) for each 
     year occurring after 2009 and before such year.

       ``(iii) Class independence fund reserves.--At such time as 
     the CLASS program has been in operation for 10 years, the 
     Secretary shall establish all premiums to be paid by 
     enrollees for the year based on an actuarial analysis that 
     accumulated reserves in the CLASS Independence Fund would not 
     decrease in that year. At such time as the Secretary 
     determines the CLASS program demonstrates a sustained ability 
     to finance expected yearly expenses with expected yearly 
     premiums and interest credited to the CLASS Independence 
     Fund, the Secretary may decrease the required amount of CLASS 
     Independence Fund reserves.
       ``(B) Vesting period.--A 5-year vesting period for 
     eligibility for benefits.

[[Page 4393]]

       ``(C) Benefit triggers.--A benefit trigger for provision of 
     benefits that requires a determination that an individual has 
     a functional limitation, as certified by a licensed health 
     care practitioner, described in any of the following clauses 
     that is expected to last for a continuous period of more than 
     90 days:
       ``(i) The individual is determined to be unable to perform 
     at least the minimum number (which may be 2 or 3) of 
     activities of daily living as are required under the plan for 
     the provision of benefits without substantial assistance (as 
     defined by the Secretary) from another individual.
       ``(ii) The individual requires substantial supervision to 
     protect the individual from threats to health and safety due 
     to substantial cognitive impairment.
       ``(iii) The individual has a level of functional limitation 
     similar (as determined under regulations prescribed by the 
     Secretary) to the level of functional limitation described in 
     clause (i) or (ii).
       ``(D) Cash benefit.--Payment of a cash benefit that 
     satisfies the following requirements:
       ``(i) Minimum required amount.--The benefit amount provides 
     an eligible beneficiary with not less than an average of $50 
     per day (as determined based on the reasonably expected 
     distribution of beneficiaries receiving benefits at various 
     benefit levels).
       ``(ii) Amount scaled to functional ability.--The benefit 
     amount is varied based on a scale of functional ability, with 
     not less than 2, and not more than 6, benefit level amounts.
       ``(iii) Daily or weekly.--The benefit is paid on a daily or 
     weekly basis.
       ``(iv) No lifetime or aggregate limit.--The benefit is not 
     subject to any lifetime or aggregate limit.
       ``(E) Coordination with supplemental coverage obtained 
     through the exchange.--The benefits allow for coordination 
     with any supplemental coverage purchased through an Exchange 
     established under section 1311 of the Patient Protection and 
     Affordable Care Act.
       ``(2) Review and recommendation by the class independence 
     advisory council.--The CLASS Independence Advisory Council 
     shall--
       ``(A) evaluate the alternative benefit plans developed 
     under paragraph (1); and
       ``(B) recommend for designation as the CLASS Independence 
     Benefit Plan for offering to the public the plan that the 
     Council determines best balances price and benefits to meet 
     enrollees' needs in an actuarially sound manner, while 
     optimizing the probability of the long-term sustainability of 
     the CLASS program.
       ``(3) Designation by the secretary.--Not later than October 
     1, 2012, the Secretary, taking into consideration the 
     recommendation of the CLASS Independence Advisory Council 
     under paragraph (2)(B), shall designate a benefit plan as the 
     CLASS Independence Benefit Plan. The Secretary shall publish 
     such designation, along with details of the plan and the 
     reasons for the selection by the Secretary, in a final rule 
     that allows for a period of public comment.
       ``(b) Additional Premium Requirements.--
       ``(1) Adjustment of premiums.--
       ``(A) In general.--Except as provided in subparagraphs (B), 
     (C), (D), and (E), the amount of the monthly premium 
     determined for an individual upon such individual's 
     enrollment in the CLASS program shall remain the same for as 
     long as the individual is an active enrollee in the program.
       ``(B) Recalculated premium if required for program 
     solvency.--
       ``(i) In general.--Subject to clause (ii), if the Secretary 
     determines, based on the most recent report of the Board of 
     Trustees of the CLASS Independence Fund, the advice of the 
     CLASS Independence Advisory Council, and the annual report of 
     the Inspector General of the Department of Health and Human 
     Services, and waste, fraud, and abuse, or such other 
     information as the Secretary determines appropriate, that the 
     monthly premiums and income to the CLASS Independence Fund 
     for a year are projected to be insufficient with respect to 
     the 20-year period that begins with that year, the Secretary 
     shall adjust the monthly premiums for individuals enrolled in 
     the CLASS program as necessary (but maintaining a nominal 
     premium for enrollees whose income is below the poverty line 
     or who are full-time students actively employed).
       ``(ii) Exemption from increase.--Any increase in a monthly 
     premium imposed as result of a determination described in 
     clause (i) shall not apply with respect to the monthly 
     premium of any active enrollee who--

       ``(I) has attained age 65;
       ``(II) has paid premiums for enrollment in the program for 
     at least 20 years; and
       ``(III) is not actively employed.

       ``(C) Recalculated premium if reenrollment after more than 
     a 3-month lapse.--
       ``(i) In general.--The reenrollment of an individual after 
     a 90-day period during which the individual failed to pay the 
     monthly premium required to maintain the individual's 
     enrollment in the CLASS program shall be treated as an 
     initial enrollment for purposes of age-adjusting the premium 
     for enrollment in the program.
       ``(ii) Credit for prior months if reenrolled within 5 
     years.--An individual who reenrolls in the CLASS program 
     after such a 90-day period and before the end of the 5-year 
     period that begins with the first month for which the 
     individual failed to pay the monthly premium required to 
     maintain the individual's enrollment in the program shall 
     be--

       ``(I) credited with any months of paid premiums that 
     accrued prior to the individual's lapse in enrollment; and
       ``(II) notwithstanding the total amount of any such 
     credited months, required to satisfy section 3202(6)(A)(ii) 
     before being eligible to receive benefits.

       ``(D) No longer status as a full-time student.--An 
     individual subject to a nominal premium on the basis of being 
     described in subsection (a)(1)(A)(ii)(I)(bb) who ceases to be 
     described in that subsection, beginning with the first month 
     following the month in which the individual ceases to be so 
     described, shall be subject to the same monthly premium as 
     the monthly premium that applies to an individual of the same 
     age who first enrolls in the program under the most similar 
     circumstances as the individual (such as the first year of 
     eligibility for enrollment in the program or in a subsequent 
     year).
       ``(E) Penalty for reenollment after 5-year lapse.--In the 
     case of an individual who reenrolls in the CLASS program 
     after the end of the 5-year period described in subparagraph 
     (C)(ii), the monthly premium required for the individual 
     shall be the age-adjusted premium that would be applicable to 
     an initially enrolling individual who is the same age as the 
     reenrolling individual, increased by the greater of--
       ``(i) an amount that the Secretary determines is 
     actuarially sound for each month that occurs during the 
     period that begins with the first month for which the 
     individual failed to pay the monthly premium required to 
     maintain the individual's enrollment in the CLASS program and 
     ends with the month preceding the month in which the 
     reenollment is effective; or
       ``(ii) 1 percent of the applicable age-adjusted premium for 
     each such month occurring in such period.
       ``(2) Administrative expenses.--In determining the monthly 
     premiums for the CLASS program the Secretary may factor in 
     costs for administering the program, not to exceed for any 
     year in which the program is in effect under this title, an 
     amount equal to 3 percent of all premiums paid during the 
     year.
       ``(3) No underwriting requirements.--No underwriting (other 
     than on the basis of age in accordance with subparagraphs (D) 
     and (E) of paragraph (1)) shall be used to--
       ``(A) determine the monthly premium for enrollment in the 
     CLASS program; or
       ``(B) prevent an individual from enrolling in the program.
       ``(c) Self-attestation and Verification of Income.--The 
     Secretary shall establish procedures to--
       ``(1) permit an individual who is eligible for the nominal 
     premium required under subsection (a)(1)(A)(ii), as part of 
     their automatic enrollment in the CLASS program, to self-
     attest that their income does not exceed the poverty line or 
     that their status as a full-time student who is actively 
     employed;
       ``(2) verify, using procedures similar to the procedures 
     used by the Commissioner of Social Security under section 
     1631(e)(1)(B)(ii) of the Social Security Act and consistent 
     with the requirements applicable to the conveyance of data 
     and information under section 1942 of such Act, the validity 
     of such self-attestation; and
       ``(3) require an individual to confirm, on at least an 
     annual basis, that their income does not exceed the poverty 
     line or that they continue to maintain such status.

     ``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.

       ``(a) Automatic Enrollment.--
       ``(1) In general.--Subject to paragraph (2), the Secretary, 
     in coordination with the Secretary of the Treasury, shall 
     establish procedures under which each individual described in 
     subsection (c) may be automatically enrolled in the CLASS 
     program by an employer of such individual in the same manner 
     as an employer may elect to automatically enroll employees in 
     a plan under section 401(k), 403(b), or 457 of the Internal 
     Revenue Code of 1986.
       ``(2) Alternative enrollment procedures.--The procedures 
     established under paragraph (1) shall provide for an 
     alternative enrollment process for an individual described in 
     subsection (c) in the case of such an individual--
       ``(A) who is self-employed;
       ``(B) who has more than 1 employer; or
       ``(C) whose employer does not elect to participate in the 
     automatic enrollment process established by the Secretary.
       ``(3) Administration.--
       ``(A) In general.--The Secretary and the Secretary of the 
     Treasury shall, by regulation, establish procedures to ensure 
     that an individual is not automatically enrolled in the CLASS 
     program by more than 1 employer.
       ``(B) Form.--Enrollment in the CLASS program shall be made 
     in such manner as the Secretary may prescribe in order to 
     ensure ease of administration.
       ``(b) Election to Opt-Out.--An individual described in 
     subsection (c) may elect to waive enrollment in the CLASS 
     program at any time in such form and manner as the Secretary 
     and the Secretary of the Treasury shall prescribe.
       ``(c) Individual Described.--For purposes of enrolling in 
     the CLASS program, an individual described in this paragraph 
     is an individual--
       ``(1) who has attained age 18;
       ``(2) who--
       ``(A) receives wages on which there is imposed a tax under 
     section 3201(a) of the Internal Revenue Code of 1986; or
       ``(B) derives self-employment income on which there is 
     imposed a tax under section 1401(a) of the Internal Revenue 
     Code of 1986;
       ``(3) who is actively employed; and
       ``(4) who is not--
       ``(A) a patient in a hospital or nursing facility, an 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases and receiving medical 
     assistance under Medicaid; or

[[Page 4394]]

       ``(B) confined in a jail, prison, other penal institution 
     or correctional facility, or by court order pursuant to 
     conviction of a criminal offense or in connection with a 
     verdict or finding described in section 202(x)(1)(A)(ii) of 
     the Social Security Act (42 U.S.C. 402(x)(1)(A)(ii)).
       ``(d) Rule of Construction.--Nothing in this title shall be 
     construed as requiring an active enrollee to continue to 
     satisfy subparagraph (B) or (C) of subsection (c)(1) in order 
     to maintain enrollment in the CLASS program.
       ``(e) Payment.--
       ``(1) Payroll deduction.--An amount equal to the monthly 
     premium for the enrollment in the CLASS program of an 
     individual shall be deducted from the wages or self-
     employment income of such individual in accordance with such 
     procedures as the Secretary, in coordination with the 
     Secretary of the Treasury, shall establish for employers who 
     elect to deduct and withhold such premiums on behalf of 
     enrolled employees.
       ``(2) Alternative payment mechanism.--The Secretary, in 
     coordination with the Secretary of the Treasury, shall 
     establish alternative procedures for the payment of monthly 
     premiums by an individual enrolled in the CLASS program--
       ``(A) who does not have an employer who elects to deduct 
     and withhold premiums in accordance with subparagraph (A); or
       ``(B) who does not earn wages or derive self-employment 
     income.
       ``(f) Transfer of Premiums Collected.--
       ``(1) In general.--During each calendar year the Secretary 
     of the Treasury shall deposit into the CLASS Independence 
     Fund a total amount equal, in the aggregate, to 100 percent 
     of the premiums collected during that year.
       ``(2) Transfers based on estimates.--The amount deposited 
     pursuant to paragraph (1) shall be transferred in at least 
     monthly payments to the CLASS Independence Fund on the basis 
     of estimates by the Secretary and certified to the Secretary 
     of the Treasury of the amounts collected in accordance with 
     subparagraphs (A) and (B) of paragraph (5). Proper 
     adjustments shall be made in amounts subsequently transferred 
     to the Fund to the extent prior estimates were in excess of, 
     or were less than, actual amounts collected.
       ``(g) Other Enrollment and Disenrollment Opportunities.--
     The Secretary, in coordination with the Secretary of the 
     Treasury, shall establish procedures under which--
       ``(1) an individual who, in the year of the individual's 
     initial eligibility to enroll in the CLASS program, has 
     elected to waive enrollment in the program, is eligible to 
     elect to enroll in the program, in such form and manner as 
     the Secretaries shall establish, only during an open 
     enrollment period established by the Secretaries that is 
     specific to the individual and that may not occur more 
     frequently than biennially after the date on which the 
     individual first elected to waive enrollment in the program; 
     and
       ``(2) an individual shall only be permitted to disenroll 
     from the program (other than for nonpayment of premiums) 
     during an annual disenrollment period established by the 
     Secretaries and in such form and manner as the Secretaries 
     shall establish.

     ``SEC. 3205. BENEFITS.

       ``(a) Determination of Eligibility.--
       ``(1) Application for receipt of benefits.--The Secretary 
     shall establish procedures under which an active enrollee 
     shall apply for receipt of benefits under the CLASS 
     Independence Benefit Plan.
       ``(2) Eligibility assessments.--
       ``(A) In general.--Not later than January 1, 2012, the 
     Secretary shall--
       ``(i) establish an Eligibility Assessment System (other 
     than a service with which the Commissioner of Social Security 
     has entered into an agreement, with respect to any State, to 
     make disability determinations for purposes of title II or 
     XVI of the Social Security Act) to provide for eligibility 
     assessments of active enrollees who apply for receipt of 
     benefits;
       ``(ii) enter into an agreement with the Protection and 
     Advocacy System for each State to provide advocacy services 
     in accordance with subsection (d); and
       ``(iii) enter into an agreement with public and private 
     entities to provide advice and assistance counseling in 
     accordance with subsection (e).
       ``(B) Regulations.--The Secretary shall promulgate 
     regulations to develop an expedited nationally equitable 
     eligibility determination process, as certified by a licensed 
     health care practitioner, an appeals process, and a 
     redetermination process, as certified by a licensed health 
     care practitioner, including whether an active enrollee is 
     eligible for a cash benefit under the program and if so, the 
     amount of the cash benefit (in accordance the sliding scale 
     established under the plan).
       ``(C) Presumptive eligibility for certain institutionalized 
     enrollees planning to discharge.--An active enrollee shall be 
     deemed presumptively eligible if the enrollee--
       ``(i) has applied for, and attests is eligible for, the 
     maximum cash benefit available under the sliding scale 
     established under the CLASS Independence Benefit Plan;
       ``(ii) is a patient in a hospital (but only if the 
     hospitalization is for long-term care), nursing facility, 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases; and
       ``(iii) is in the process of, or about to begin the process 
     of, planning to discharge from the hospital, facility, or 
     institution, or within 60 days from the date of discharge 
     from the hospital, facility, or institution.
       ``(D) Appeals.--The Secretary shall establish procedures 
     under which an applicant for benefits under the CLASS 
     Independence Benefit Plan shall be guaranteed the right to 
     appeal an adverse determination.
       ``(b) Benefits.--An eligible beneficiary shall receive the 
     following benefits under the CLASS Independence Benefit Plan:
       ``(1) Cash benefit.--A cash benefit established by the 
     Secretary in accordance with the requirements of section 
     3203(a)(1)(D) that--
       ``(A) the first year in which beneficiaries receive the 
     benefits under the plan, is not less than the average dollar 
     amount specified in clause (i) of such section; and
       ``(B) for any subsequent year, is not less than the average 
     per day dollar limit applicable under this subparagraph for 
     the preceding year, increased by the percentage increase in 
     the consumer price index for all urban consumers (U.S. city 
     average) over the previous year.
       ``(2) Advocacy services.--Advocacy services in accordance 
     with subsection (d).
       ``(3) Advice and assistance counseling.--Advice and 
     assistance counseling in accordance with subsection (e).
       ``(4) Administrative expenses.--Advocacy services and 
     advise and assistance counseling services under paragraphs 
     (2) and (3) of this subsection shall be included as 
     administrative expenses under section 3203(b)(3).
       ``(c) Payment of Benefits.--
       ``(1) Life independence account.--
       ``(A) In general.--The Secretary shall establish procedures 
     for administering the provision of benefits to eligible 
     beneficiaries under the CLASS Independence Benefit Plan, 
     including the payment of the cash benefit for the beneficiary 
     into a Life Independence Account established by the Secretary 
     on behalf of each eligible beneficiary.
       ``(B) Use of cash benefits.--Cash benefits paid into a Life 
     Independence Account of an eligible beneficiary shall be used 
     to purchase nonmedical services and supports that the 
     beneficiary needs to maintain his or her independence at home 
     or in another residential setting of their choice in the 
     community, including (but not limited to) home modifications, 
     assistive technology, accessible transportation, homemaker 
     services, respite care, personal assistance services, home 
     care aides, and nursing support. Nothing in the preceding 
     sentence shall prevent an eligible beneficiary from using 
     cash benefits paid into a Life Independence Account for 
     obtaining assistance with decision making concerning medical 
     care, including the right to accept or refuse medical or 
     surgical treatment and the right to formulate advance 
     directives or other written instructions recognized under 
     State law, such as a living will or durable power of attorney 
     for health care, in the case that an injury or illness causes 
     the individual to be unable to make health care decisions.
       ``(C) Electronic management of funds.--The Secretary shall 
     establish procedures for--
       ``(i) crediting an account established on behalf of a 
     beneficiary with the beneficiary's cash daily benefit;
       ``(ii) allowing the beneficiary to access such account 
     through debit cards; and
       ``(iii) accounting for withdrawals by the beneficiary from 
     such account.
       ``(D) Primary payor rules for beneficiaries who are 
     enrolled in medicaid.--In the case of an eligible beneficiary 
     who is enrolled in Medicaid, the following payment rules 
     shall apply:
       ``(i) Institutionalized beneficiary.--If the beneficiary is 
     a patient in a hospital, nursing facility, intermediate care 
     facility for the mentally retarded, or an institution for 
     mental diseases, the beneficiary shall retain an amount equal 
     to 5 percent of the beneficiary's daily or weekly cash 
     benefit (as applicable) (which shall be in addition to the 
     amount of the beneficiary's personal needs allowance provided 
     under Medicaid), and the remainder of such benefit shall be 
     applied toward the facility's cost of providing the 
     beneficiary's care, and Medicaid shall provide secondary 
     coverage for such care.
       ``(ii) Beneficiaries receiving home and community-based 
     services.--

       ``(I) 50 percent of benefit retained by beneficiary.--
     Subject to subclause (II), if a beneficiary is receiving 
     medical assistance under Medicaid for home and community 
     based services, the beneficiary shall retain an amount equal 
     to 50 percent of the beneficiary's daily or weekly cash 
     benefit (as applicable), and the remainder of the daily or 
     weekly cash benefit shall be applied toward the cost to the 
     State of providing such assistance (and shall not be used to 
     claim Federal matching funds under Medicaid), and Medicaid 
     shall provide secondary coverage for the remainder of any 
     costs incurred in providing such assistance.
       ``(II) Requirement for state offset.--A State shall be paid 
     the remainder of a beneficiary's daily or weekly cash benefit 
     under subclause (I) only if the State home and community-
     based waiver under section 1115 of the Social Security Act 
     (42 U.S.C. 1315) or subsection (c) or (d) of section 1915 of 
     such Act (42 U.S.C. 1396n), or the State plan amendment under 
     subsection (i) of such section does not include a waiver of 
     the requirements of section 1902(a)(1) of the Social Security 
     Act (relating to statewideness) or of section 1902(a)(10)(B) 
     of such Act (relating to comparability) and the State offers 
     at a minimum case management services, personal care 
     services, habilitation services, and respite care under such 
     a waiver or State plan amendment.
       ``(III) Definition of home and community-based services.--
     In this clause, the term `home and community-based services' 
     means any services which may be offered under a home and

[[Page 4395]]

     community-based waiver authorized for a State under section 
     1115 of the Social Security Act (42 U.S.C. 1315) or 
     subsection (c) or (d) of section 1915 of such Act (42 U.S.C. 
     1396n) or under a State plan amendment under subsection (i) 
     of such section.

       ``(iii) Beneficiaries enrolled in programs of all-inclusive 
     care for the elderly (pace).--

       ``(I) In general.--Subject to subclause (II), if a 
     beneficiary is receiving medical assistance under Medicaid 
     for PACE program services under section 1934 of the Social 
     Security Act (42 U.S.C. 1396u-4), the beneficiary shall 
     retain an amount equal to 50 percent of the beneficiary's 
     daily or weekly cash benefit (as applicable), and the 
     remainder of the daily or weekly cash benefit shall be 
     applied toward the cost to the State of providing such 
     assistance (and shall not be used to claim Federal matching 
     funds under Medicaid), and Medicaid shall provide secondary 
     coverage for the remainder of any costs incurred in providing 
     such assistance.
       ``(II) Institutionalized recipients of pace program 
     services.--If a beneficiary receiving assistance under 
     Medicaid for PACE program services is a patient in a 
     hospital, nursing facility, intermediate care facility for 
     the mentally retarded, or an institution for mental diseases, 
     the beneficiary shall be treated as in institutionalized 
     beneficiary under clause (i).

       ``(2) Authorized representatives.--
       ``(A) In general.--The Secretary shall establish procedures 
     to allow access to a beneficiary's cash benefits by an 
     authorized representative of the eligible beneficiary on 
     whose behalf such benefits are paid.
       ``(B) Quality assurance and protection against fraud and 
     abuse.--The procedures established under subparagraph (A) 
     shall ensure that authorized representatives of eligible 
     beneficiaries comply with standards of conduct established by 
     the Secretary, including standards requiring that such 
     representatives provide quality services on behalf of such 
     beneficiaries, do not have conflicts of interest, and do not 
     misuse benefits paid on behalf of such beneficiaries or 
     otherwise engage in fraud or abuse.
       ``(3) Commencement of benefits.--Benefits shall be paid to, 
     or on behalf of, an eligible beneficiary beginning with the 
     first month in which an application for such benefits is 
     approved.
       ``(4) Rollover option for lump-sum payment.--An eligible 
     beneficiary may elect to--
       ``(A) defer payment of their daily or weekly benefit and to 
     rollover any such deferred benefits from month-to-month, but 
     not from year-to-year; and
       ``(B) receive a lump-sum payment of such deferred benefits 
     in an amount that may not exceed the lesser of--
       ``(i) the total amount of the accrued deferred benefits; or
       ``(ii) the applicable annual benefit.
       ``(5) Period for determination of annual benefits.--
       ``(A) In general.--The applicable period for determining 
     with respect to an eligible beneficiary the applicable annual 
     benefit and the amount of any accrued deferred benefits is 
     the 12-month period that commences with the first month in 
     which the beneficiary began to receive such benefits, and 
     each 12-month period thereafter.
       ``(B) Inclusion of increased benefits.--The Secretary shall 
     establish procedures under which cash benefits paid to an 
     eligible beneficiary that increase or decrease as a result of 
     a change in the functional status of the beneficiary before 
     the end of a 12-month benefit period shall be included in the 
     determination of the applicable annual benefit paid to the 
     eligible beneficiary.
       ``(C) Recoupment of unpaid, accrued benefits.--
       ``(i) In general.--The Secretary, in coordination with the 
     Secretary of the Treasury, shall recoup any accrued benefits 
     in the event of--

       ``(I) the death of a beneficiary; or
       ``(II) the failure of a beneficiary to elect under 
     paragraph (4)(B) to receive such benefits as a lump-sum 
     payment before the end of the 12-month period in which such 
     benefits accrued.

       ``(ii) Payment into class independence fund.--Any benefits 
     recouped in accordance with clause (i) shall be paid into the 
     CLASS Independence Fund and used in accordance with section 
     3206.
       ``(6) Requirement to recertify eligibility for receipt of 
     benefits.--An eligible beneficiary shall periodically, as 
     determined by the Secretary--
       ``(A) recertify by submission of medical evidence the 
     beneficiary's continued eligibility for receipt of benefits; 
     and
       ``(B) submit records of expenditures attributable to the 
     aggregate cash benefit received by the beneficiary during the 
     preceding year.
       ``(7) Supplement, not supplant other health care 
     benefits.--Subject to the Medicaid payment rules under 
     paragraph (1)(D), benefits received by an eligible 
     beneficiary shall supplement, but not supplant, other health 
     care benefits for which the beneficiary is eligible under 
     Medicaid or any other Federally funded program that provides 
     health care benefits or assistance.
       ``(d) Advocacy Services.--An agreement entered into under 
     subsection (a)(2)(A)(ii) shall require the Protection and 
     Advocacy System for the State to--
       ``(1) assign, as needed, an advocacy counselor to each 
     eligible beneficiary that is covered by such agreement and 
     who shall provide an eligible beneficiary with--
       ``(A) information regarding how to access the appeals 
     process established for the program;
       ``(B) assistance with respect to the annual recertification 
     and notification required under subsection (c)(6); and
       ``(C) such other assistance with obtaining services as the 
     Secretary, by regulation, shall require; and
       ``(2) ensure that the System and such counselors comply 
     with the requirements of subsection (h).
       ``(e) Advice and Assistance Counseling.--An agreement 
     entered into under subsection (a)(2)(A)(iii) shall require 
     the entity to assign, as requested by an eligible beneficiary 
     that is covered by such agreement, an advice and assistance 
     counselor who shall provide an eligible beneficiary with 
     information regarding--
       ``(1) accessing and coordinating long-term services and 
     supports in the most integrated setting;
       ``(2) possible eligibility for other benefits and services;
       ``(3) development of a service and support plan;
       ``(4) information about programs established under the 
     Assistive Technology Act of 1998 and the services offered 
     under such programs;
       ``(5) available assistance with decision making concerning 
     medical care, including the right to accept or refuse medical 
     or surgical treatment and the right to formulate advance 
     directives or other written instructions recognized under 
     State law, such as a living will or durable power of attorney 
     for health care, in the case that an injury or illness causes 
     the individual to be unable to make health care decisions; 
     and
       ``(6) such other services as the Secretary, by regulation, 
     may require.
       ``(f) No Effect on Eligibility for Other Benefits.--
     Benefits paid to an eligible beneficiary under the CLASS 
     program shall be disregarded for purposes of determining or 
     continuing the beneficiary's eligibility for receipt of 
     benefits under any other Federal, State, or locally funded 
     assistance program, including benefits paid under titles II, 
     XVI, XVIII, XIX, or XXI of the Social Security Act (42 U.S.C. 
     401 et seq., 1381 et seq., 1395 et seq., 1396 et seq., 1397aa 
     et seq.), under the laws administered by the Secretary of 
     Veterans Affairs, under low-income housing assistance 
     programs, or under the supplemental nutrition assistance 
     program established under the Food and Nutrition Act of 2008 
     (7 U.S.C. 2011 et seq.).
       ``(g) Rule of Construction.--Nothing in this title shall be 
     construed as prohibiting benefits paid under the CLASS 
     Independence Benefit Plan from being used to compensate a 
     family caregiver for providing community living assistance 
     services and supports to an eligible beneficiary.
       ``(h) Protection Against Conflict of Interests.--The 
     Secretary shall establish procedures to ensure that the 
     Eligibility Assessment System, the Protection and Advocacy 
     System for a State, advocacy counselors for eligible 
     beneficiaries, and any other entities that provide services 
     to active enrollees and eligible beneficiaries under the 
     CLASS program comply with the following:
       ``(1) If the entity provides counseling or planning 
     services, such services are provided in a manner that fosters 
     the best interests of the active enrollee or beneficiary.
       ``(2) The entity has established operating procedures that 
     are designed to avoid or minimize conflicts of interest 
     between the entity and an active enrollee or beneficiary.
       ``(3) The entity provides information about all services 
     and options available to the active enrollee or beneficiary, 
     to the best of its knowledge, including services available 
     through other entities or providers.
       ``(4) The entity assists the active enrollee or beneficiary 
     to access desired services, regardless of the provider.
       ``(5) The entity reports the number of active enrollees and 
     beneficiaries provided with assistance by age, disability, 
     and whether such enrollees and beneficiaries received 
     services from the entity or another entity.
       ``(6) If the entity provides counseling or planning 
     services, the entity ensures that an active enrollee or 
     beneficiary is informed of any financial interest that the 
     entity has in a service provider.
       ``(7) The entity provides an active enrollee or beneficiary 
     with a list of available service providers that can meet the 
     needs of the active enrollee or beneficiary.

     ``SEC. 3206. CLASS INDEPENDENCE FUND.

       ``(a) Establishment of CLASS Independence Fund.--There is 
     established in the Treasury of the United States a trust fund 
     to be known as the `CLASS Independence Fund'. The Secretary 
     of the Treasury shall serve as Managing Trustee of such Fund. 
     The Fund shall consist of all amounts derived from payments 
     into the Fund under sections 3204(f) and 3205(c)(5)(C)(ii), 
     and remaining after investment of such amounts under 
     subsection (b), including additional amounts derived as 
     income from such investments. The amounts held in the Fund 
     are appropriated and shall remain available without fiscal 
     year limitation--
       ``(1) to be held for investment on behalf of individuals 
     enrolled in the CLASS program;
       ``(2) to pay the administrative expenses related to the 
     Fund and to investment under subsection (b); and
       ``(3) to pay cash benefits to eligible beneficiaries under 
     the CLASS Independence Benefit Plan.
       ``(b) Investment of Fund Balance.--The Secretary of the 
     Treasury shall invest and manage the CLASS Independence Fund 
     in the same manner, and to the same extent, as the Federal

[[Page 4396]]

     Supplementary Medical Insurance Trust Fund may be invested 
     and managed under subsections (c), (d), and (e) of section 
     1841(d) of the Social Security Act (42 U.S.C. 1395t).
       ``(c) Board of Trustees.--
       ``(1) In general.--With respect to the CLASS Independence 
     Fund, there is hereby created a body to be known as the Board 
     of Trustees of the CLASS Independence Fund (hereinafter in 
     this section referred to as the `Board of Trustees') composed 
     of the Secretary of the Treasury, the Secretary of Labor, and 
     the Secretary of Health and Human Services, all ex officio, 
     and of two members of the public (both of whom may not be 
     from the same political party), who shall be nominated by the 
     President for a term of 4 years and subject to confirmation 
     by the Senate. A member of the Board of Trustees serving as a 
     member of the public and nominated and confirmed to fill a 
     vacancy occurring during a term shall be nominated and 
     confirmed only for the remainder of such term. An individual 
     nominated and confirmed as a member of the public may serve 
     in such position after the expiration of such member's term 
     until the earlier of the time at which the member's successor 
     takes office or the time at which a report of the Board is 
     first issued under paragraph (2) after the expiration of the 
     member's term. The Secretary of the Treasury shall be the 
     Managing Trustee of the Board of Trustees. The Board of 
     Trustees shall meet not less frequently than once each 
     calendar year. A person serving on the Board of Trustees 
     shall not be considered to be a fiduciary and shall not be 
     personally liable for actions taken in such capacity with 
     respect to the Trust Fund.
       ``(2) Duties.--
       ``(A) In general.--It shall be the duty of the Board of 
     Trustees to do the following:
       ``(i) Hold the CLASS Independence Fund.
       ``(ii) Report to the Congress not later than the first day 
     of April of each year on the operation and status of the 
     CLASS Independence Fund during the preceding fiscal year and 
     on its expected operation and status during the current 
     fiscal year and the next 2 fiscal years.
       ``(iii) Report immediately to the Congress whenever the 
     Board is of the opinion that the amount of the CLASS 
     Independence Fund is not actuarially sound in regards to the 
     projection under section 3203(b)(1)(B)(i).
       ``(iv) Review the general policies followed in managing the 
     CLASS Independence Fund, and recommend changes in such 
     policies, including necessary changes in the provisions of 
     law which govern the way in which the CLASS Independence Fund 
     is to be managed.
       ``(B) Report.--The report provided for in subparagraph 
     (A)(ii) shall--
       ``(i) include--

       ``(I) a statement of the assets of, and the disbursements 
     made from, the CLASS Independence Fund during the preceding 
     fiscal year;
       ``(II) an estimate of the expected income to, and 
     disbursements to be made from, the CLASS Independence Fund 
     during the current fiscal year and each of the next 2 fiscal 
     years;
       ``(III) a statement of the actuarial status of the CLASS 
     Independence Fund for the current fiscal year, each of the 
     next 2 fiscal years, and as projected over the 75-year period 
     beginning with the current fiscal year; and
       ``(IV) an actuarial opinion by the Chief Actuary of the 
     Centers for Medicare & Medicaid Services certifying that the 
     techniques and methodologies used are generally accepted 
     within the actuarial profession and that the assumptions and 
     cost estimates used are reasonable; and

       ``(ii) be printed as a House document of the session of the 
     Congress to which the report is made.
       ``(C) Recommendations.--If the Board of Trustees determines 
     that enrollment trends and expected future benefit claims on 
     the CLASS Independence Fund are not actuarially sound in 
     regards to the projection under section 3203(b)(1)(B)(i) and 
     are unlikely to be resolved with reasonable premium increases 
     or through other means, the Board of Trustees shall include 
     in the report provided for in subparagraph (A)(ii) 
     recommendations for such legislative action as the Board of 
     Trustees determine to be appropriate, including whether to 
     adjust monthly premiums or impose a temporary moratorium on 
     new enrollments.

     ``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.

       ``(a) Establishment.--There is hereby created an Advisory 
     Committee to be known as the `CLASS Independence Advisory 
     Council'.
       ``(b) Membership.--
       ``(1) In general.--The CLASS Independence Advisory Council 
     shall be composed of not more than 15 individuals, not 
     otherwise in the employ of the United States--
       ``(A) who shall be appointed by the President without 
     regard to the civil service laws and regulations; and
       ``(B) a majority of whom shall be representatives of 
     individuals who participate or are likely to participate in 
     the CLASS program, and shall include representatives of older 
     and younger workers, individuals with disabilities, family 
     caregivers of individuals who require services and supports 
     to maintain their independence at home or in another 
     residential setting of their choice in the community, 
     individuals with expertise in long-term care or disability 
     insurance, actuarial science, economics, and other relevant 
     disciplines, as determined by the Secretary.
       ``(2) Terms.--
       ``(A) In general.--The members of the CLASS Independence 
     Advisory Council shall serve overlapping terms of 3 years 
     (unless appointed to fill a vacancy occurring prior to the 
     expiration of a term, in which case the individual shall 
     serve for the remainder of the term).
       ``(B) Limitation.--A member shall not be eligible to serve 
     for more than 2 consecutive terms.
       ``(3) Chair.--The President shall, from time to time, 
     appoint one of the members of the CLASS Independence Advisory 
     Council to serve as the Chair.
       ``(c) Duties.--The CLASS Independence Advisory Council 
     shall advise the Secretary on matters of general policy in 
     the administration of the CLASS program established under 
     this title and in the formulation of regulations under this 
     title including with respect to--
       ``(1) the development of the CLASS Independence Benefit 
     Plan under section 3203;
       ``(2) the determination of monthly premiums under such 
     plan; and
       ``(3) the financial solvency of the program.
       ``(d) Application of FACA.--The Federal Advisory Committee 
     Act (5 U.S.C. App.), other than section 14 of that Act, shall 
     apply to the CLASS Independence Advisory Council.
       ``(e) Authorization of Appropriations.--
       ``(1) In general.--There are authorized to be appropriated 
     to the CLASS Independence Advisory Council to carry out its 
     duties under this section, such sums as may be necessary for 
     fiscal year 2011 and for each fiscal year thereafter.
       ``(2) Availability.--Any sums appropriated under the 
     authorization contained in this section shall remain 
     available, without fiscal year limitation, until expended.

     ``SEC. 3208. SOLVENCY AND FISCAL INDEPENDENCE; REGULATIONS; 
                   ANNUAL REPORT.

       ``(a) Solvency.--The Secretary shall regularly consult with 
     the Board of Trustees of the CLASS Independence Fund and the 
     CLASS Independence Advisory Council, for purposes of ensuring 
     that enrollees premiums are adequate to ensure the financial 
     solvency of the CLASS program, both with respect to fiscal 
     years occurring in the near-term and fiscal years occurring 
     over 20- and 75-year periods, taking into account the 
     projections required for such periods under subsections 
     (a)(1)(A)(i) and (b)(1)(B)(i) of section 3202.
       ``(b) No Taxpayer Funds Used To Pay Benefits.--No taxpayer 
     funds shall be used for payment of benefits under a CLASS 
     Independent Benefit Plan. For purposes of this subsection, 
     the term `taxpayer funds' means any Federal funds from a 
     source other than premiums deposited by CLASS program 
     participants in the CLASS Independence Fund and any 
     associated interest earnings.
       ``(c) Regulations.--The Secretary shall promulgate such 
     regulations as are necessary to carry out the CLASS program 
     in accordance with this title. Such regulations shall include 
     provisions to prevent fraud and abuse under the program.
       ``(d) Annual Report.--Beginning January 1, 2014, the 
     Secretary shall submit an annual report to Congress on the 
     CLASS program. Each report shall include the following:
       ``(1) The total number of enrollees in the program.
       ``(2) The total number of eligible beneficiaries during the 
     fiscal year.
       ``(3) The total amount of cash benefits provided during the 
     fiscal year.
       ``(4) A description of instances of fraud or abuse 
     identified during the fiscal year.
       ``(5) Recommendations for such administrative or 
     legislative action as the Secretary determines is necessary 
     to improve the program, ensure the solvency of the program, 
     or to prevent the occurrence of fraud or abuse.

     ``SEC. 3209. INSPECTOR GENERAL'S REPORT.

       ``The Inspector General of the Department of Health and 
     Human Services shall submit an annual report to the Secretary 
     and Congress relating to the overall progress of the CLASS 
     program and of the existence of waste, fraud, and abuse in 
     the CLASS program. Each such report shall include findings in 
     the following areas:
       ``(1) The eligibility determination process.
       ``(2) The provision of cash benefits.
       ``(3) Quality assurance and protection against waste, 
     fraud, and abuse.
       ``(4) Recouping of unpaid and accrued benefits.

     ``SEC. 3210. TAX TREATMENT OF PROGRAM.

       ``The CLASS program shall be treated for purposes of the 
     Internal Revenue Code of 1986 in the same manner as a 
     qualified long-term care insurance contract for qualified 
     long-term care services.''.
       (2) Conforming amendments to medicaid.--Section 1902(a) of 
     the Social Security Act (42 U.S.C. 1396a(a)), as amended by 
     section 6505, is amended by inserting after paragraph (80) 
     the following:
       ``(81) provide that the State will comply with such 
     regulations regarding the application of primary and 
     secondary payor rules with respect to individuals who are 
     eligible for medical assistance under this title and are 
     eligible beneficiaries under the CLASS program established 
     under title XXXII of the Public Health Service Act as the 
     Secretary shall establish; and''.
       (b) Assurance of Adequate Infrastructure for the Provision 
     of Personal Care Attendant Workers.--Section 1902(a) of the 
     Social Security Act (42 U.S.C. 1396a(a)), as amended by 
     subsection (a)(2), is amended by inserting after paragraph 
     (81) the following:
       ``(82) provide that, not later than 2 years after the date 
     of enactment of the Community Living Assistance Services and 
     Supports Act, each State shall--
       ``(A) assess the extent to which entities such as providers 
     of home care, home health services, home and community 
     service providers, public

[[Page 4397]]

      authorities created to provide personal care services to 
     individuals eligible for medical assistance under the State 
     plan, and nonprofit organizations, are serving or have the 
     capacity to serve as fiscal agents for, employers of, and 
     providers of employment-related benefits for, personal care 
     attendant workers who provide personal care services to 
     individuals receiving benefits under the CLASS program 
     established under title XXXII of the Public Health Service 
     Act, including in rural and underserved areas;
       ``(B) designate or create such entities to serve as fiscal 
     agents for, employers of, and providers of employment-related 
     benefits for, such workers to ensure an adequate supply of 
     the workers for individuals receiving benefits under the 
     CLASS program, including in rural and underserved areas; and
       ``(C) ensure that the designation or creation of such 
     entities will not negatively alter or impede existing 
     programs, models, methods, or administration of service 
     delivery that provide for consumer controlled or self-
     directed home and community services and further ensure that 
     such entities will not impede the ability of individuals to 
     direct and control their home and community services, 
     including the ability to select, manage, dismiss, co-employ, 
     or employ such workers or inhibit such individuals from 
     relying on family members for the provision of personal care 
     services.''.
       (c) Personal Care Attendants Workforce Advisory Panel.--
       (1) Establishment.--Not later than 90 days after the date 
     of enactment of this Act, the Secretary of Health and Human 
     Services shall establish a Personal Care Attendants Workforce 
     Advisory Panel for the purpose of examining and advising the 
     Secretary and Congress on workforce issues related to 
     personal care attendant workers, including with respect to 
     the adequacy of the number of such workers, the salaries, 
     wages, and benefits of such workers, and access to the 
     services provided by such workers.
       (2) Membership.--In appointing members to the Personal Care 
     Attendants Workforce Advisory Panel, the Secretary shall 
     ensure that such members include the following:
       (A) Individuals with disabilities of all ages.
       (B) Senior individuals.
       (C) Representatives of individuals with disabilities.
       (D) Representatives of senior individuals.
       (E) Representatives of workforce and labor organizations.
       (F) Representatives of home and community-based service 
     providers.
       (G) Representatives of assisted living providers.
       (d) Inclusion of Information on Supplemental Coverage in 
     the National Clearinghouse for Long-term Care Information; 
     Extension of Funding.--Section 6021(d) of the Deficit 
     Reduction Act of 2005 (42 U.S.C. 1396p note) is amended--
       (1) in paragraph (2)(A)--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) in clause (iii), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(iv) include information regarding the CLASS program 
     established under title XXXII of the Public Health Service 
     Act and coverage available for purchase through a Exchange 
     established under section 1311 of the Patient Protection and 
     Affordable Care Act that is supplemental coverage to the 
     benefits provided under a CLASS Independence Benefit Plan 
     under that program, and information regarding how benefits 
     provided under a CLASS Independence Benefit Plan differ from 
     disability insurance benefits.''; and
       (2) in paragraph (3), by striking ``2010'' and inserting 
     ``2015''.
       (e) Effective Date.--The amendments made by subsections 
     (a), (b), and (d) take effect on January 1, 2011.
       (f) Rule of Construction.--Nothing in this title or the 
     amendments made by this title are intended to replace or 
     displace public or private disability insurance benefits, 
     including such benefits that are for income replacement.

                      TITLE IX--REVENUE PROVISIONS

                 Subtitle A--Revenue Offset Provisions

     SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH 
                   COVERAGE.

       (a) In General.--Chapter 43 of the Internal Revenue Code of 
     1986, as amended by section 1513, is amended by adding at the 
     end the following:

     ``SEC. 4980I. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED 
                   HEALTH COVERAGE.

       ``(a) Imposition of Tax.--If--
       ``(1) an employee is covered under any applicable employer-
     sponsored coverage of an employer at any time during a 
     taxable period, and
       ``(2) there is any excess benefit with respect to the 
     coverage,

     there is hereby imposed a tax equal to 40 percent of the 
     excess benefit.
       ``(b) Excess Benefit.--For purposes of this section--
       ``(1) In general.--The term `excess benefit' means, with 
     respect to any applicable employer-sponsored coverage made 
     available by an employer to an employee during any taxable 
     period, the sum of the excess amounts determined under 
     paragraph (2) for months during the taxable period.
       ``(2) Monthly excess amount.--The excess amount determined 
     under this paragraph for any month is the excess (if any) 
     of--
       ``(A) the aggregate cost of the applicable employer-
     sponsored coverage of the employee for the month, over
       ``(B) an amount equal to \1/12\ of the annual limitation 
     under paragraph (3) for the calendar year in which the month 
     occurs.
       ``(3) Annual limitation.--For purposes of this subsection--
       ``(A) In general.--The annual limitation under this 
     paragraph for any calendar year is the dollar limit 
     determined under subparagraph (C) for the calendar year.
       ``(B) Applicable annual limitation.--The annual limitation 
     which applies for any month shall be determined on the basis 
     of the type of coverage (as determined under subsection 
     (f)(1)) provided to the employee by the employer as of the 
     beginning of the month.
       ``(C) Applicable dollar limit.--Except as provided in 
     subparagraph (D)--
       ``(i) 2013.--In the case of 2013, the dollar limit under 
     this subparagraph is--

       ``(I) in the case of an employee with self-only coverage, 
     $8,500, and
       ``(II) in the case of an employee with coverage other than 
     self-only coverage, $23,000.

       ``(ii) Exception for certain individuals.--In the case of 
     an individual who is a qualified retiree or who participates 
     in a plan sponsored by an employer the majority of whose 
     employees are engaged in a high-risk profession or employed 
     to repair or install electrical or telecommunications lines--

       ``(I) the dollar amount in clause (i)(I) (determined after 
     the application of subparagraph (D)) shall be increased by 
     $1,350, and
       ``(II) the dollar amount in clause (i)(II) (determined 
     after the application of subparagraph (D)) shall be increased 
     by $3,000.

       ``(iii) Subsequent years.--In the case of any calendar year 
     after 2013, each of the dollar amounts under clauses (i) and 
     (ii) shall be increased to the amount equal to such amount as 
     in effect for the calendar year preceding such year, 
     increased by an amount equal to the product of--

       ``(I) such amount as so in effect, multiplied by
       ``(II) the cost-of-living adjustment determined under 
     section 1(f)(3) for such year (determined by substituting the 
     calendar year that is 2 years before such year for `1992' in 
     subparagraph (B) thereof), increased by 1 percentage point.

     If any amount determined under this clause is not a multiple 
     of $50, such amount shall be rounded to the nearest multiple 
     of $50.
       ``(D) Transition rule for states with highest coverage 
     costs.--
       ``(i) In general.--If an employee is a resident of a high 
     cost State on the first day of any month beginning in 2013, 
     2014, or 2015, the annual limitation under this paragraph for 
     such month with respect to such employee shall be an amount 
     equal to the applicable percentage of the annual limitation 
     (determined without regard to this subparagraph or 
     subparagraph (C)(ii)).
       ``(ii) Applicable percentage.--The applicable percentage is 
     120 percent for 2013, 110 percent for 2014, and 105 percent 
     for 2015.
       ``(iii) High cost state.--The term `high cost State' means 
     each of the 17 States which the Secretary of Health and Human 
     Services, in consultation with the Secretary, estimates had 
     the highest average cost during 2012 for employer-sponsored 
     coverage under health plans. The Secretary's estimate shall 
     be made on the basis of aggregate premiums paid in the State 
     for such health plans, determined using the most recent data 
     available as of August 31, 2012.
       ``(c) Liability To Pay Tax.--
       ``(1) In general.--Each coverage provider shall pay the tax 
     imposed by subsection (a) on its applicable share of the 
     excess benefit with respect to an employee for any taxable 
     period.
       ``(2) Coverage provider.--For purposes of this subsection, 
     the term `coverage provider' means each of the following:
       ``(A) Health insurance coverage.--If the applicable 
     employer-sponsored coverage consists of coverage under a 
     group health plan which provides health insurance coverage, 
     the health insurance issuer.
       ``(B) HSA and msa contributions.--If the applicable 
     employer-sponsored coverage consists of coverage under an 
     arrangement under which the employer makes contributions 
     described in subsection (b) or (d) of section 106, the 
     employer.
       ``(C) Other coverage.--In the case of any other applicable 
     employer-sponsored coverage, the person that administers the 
     plan benefits.
       ``(3) Applicable share.--For purposes of this subsection, a 
     coverage provider's applicable share of an excess benefit for 
     any taxable period is the amount which bears the same ratio 
     to the amount of such excess benefit as--
       ``(A) the cost of the applicable employer-sponsored 
     coverage provided by the provider to the employee during such 
     period, bears to
       ``(B) the aggregate cost of all applicable employer-
     sponsored coverage provided to the employee by all coverage 
     providers during such period.
       ``(4) Responsibility to calculate tax and applicable 
     shares.--
       ``(A) In general.--Each employer shall--
       ``(i) calculate for each taxable period the amount of the 
     excess benefit subject to the tax imposed by subsection (a) 
     and the applicable share of such excess benefit for each 
     coverage provider, and
       ``(ii) notify, at such time and in such manner as the 
     Secretary may prescribe, the Secretary and each coverage 
     provider of the amount so determined for the provider.
       ``(B) Special rule for multiemployer plans.--In the case of 
     applicable employer-sponsored coverage made available to 
     employees through a multiemployer plan (as defined in

[[Page 4398]]

     section 414(f)), the plan sponsor shall make the 
     calculations, and provide the notice, required under 
     subparagraph (A).
       ``(d) Applicable Employer-Sponsored Coverage; Cost.--For 
     purposes of this section--
       ``(1) Applicable employer-sponsored coverage.--
       ``(A) In general.--The term `applicable employer-sponsored 
     coverage' means, with respect to any employee, coverage under 
     any group health plan made available to the employee by an 
     employer which is excludable from the employee's gross income 
     under section 106, or would be so excludable if it were 
     employer-provided coverage (within the meaning of such 
     section 106).
       ``(B) Exceptions.--The term `applicable employer-sponsored 
     coverage' shall not include--
       ``(i) any coverage (whether through insurance or otherwise) 
     described in section 9832(c)(1)(A) or for long-term care, or
       ``(ii) any coverage described in section 9832(c)(3) the 
     payment for which is not excludable from gross income and for 
     which a deduction under section 162(l) is not allowable.
       ``(C) Coverage includes employee paid portion.--Coverage 
     shall be treated as applicable employer-sponsored coverage 
     without regard to whether the employer or employee pays for 
     the coverage.
       ``(D) Self-employed individual.--In the case of an 
     individual who is an employee within the meaning of section 
     401(c)(1), coverage under any group health plan providing 
     health insurance coverage shall be treated as applicable 
     employer-sponsored coverage if a deduction is allowable under 
     section 162(l) with respect to all or any portion of the cost 
     of the coverage.
       ``(E) Governmental plans included.--Applicable employer-
     sponsored coverage shall include coverage under any group 
     health plan established and maintained primarily for its 
     civilian employees by the Government of the United States, by 
     the government of any State or political subdivision thereof, 
     or by any agency or instrumentality of any such government.
       ``(2) Determination of cost.--
       ``(A) In general.--The cost of applicable employer-
     sponsored coverage shall be determined under rules similar to 
     the rules of section 4980B(f)(4), except that in determining 
     such cost, any portion of the cost of such coverage which is 
     attributable to the tax imposed under this section shall not 
     be taken into account and the amount of such cost shall be 
     calculated separately for self-only coverage and other 
     coverage. In the case of applicable employer-sponsored 
     coverage which provides coverage to retired employees, the 
     plan may elect to treat a retired employee who has not 
     attained the age of 65 and a retired employee who has 
     attained the age of 65 as similarly situated beneficiaries.
       ``(B) Health fsas.--In the case of applicable employer-
     sponsored coverage consisting of coverage under a flexible 
     spending arrangement (as defined in section 106(c)(2)), the 
     cost of the coverage shall be equal to the sum of--
       ``(i) the amount of employer contributions under any salary 
     reduction election under the arrangement, plus
       ``(ii) the amount determined under subparagraph (A) with 
     respect to any reimbursement under the arrangement in excess 
     of the contributions described in clause (i).
       ``(C) Archer msas and hsas.--In the case of applicable 
     employer-sponsored coverage consisting of coverage under an 
     arrangement under which the employer makes contributions 
     described in subsection (b) or (d) of section 106, the cost 
     of the coverage shall be equal to the amount of employer 
     contributions under the arrangement.
       ``(D) Allocation on a monthly basis.--If cost is determined 
     on other than a monthly basis, the cost shall be allocated to 
     months in a taxable period on such basis as the Secretary may 
     prescribe.
       ``(e) Penalty for Failure To Properly Calculate Excess 
     Benefit.--
       ``(1) In general.--If, for any taxable period, the tax 
     imposed by subsection (a) exceeds the tax determined under 
     such subsection with respect to the total excess benefit 
     calculated by the employer or plan sponsor under subsection 
     (c)(4)--
       ``(A) each coverage provider shall pay the tax on its 
     applicable share (determined in the same manner as under 
     subsection (c)(4)) of the excess, but no penalty shall be 
     imposed on the provider with respect to such amount, and
       ``(B) the employer or plan sponsor shall, in addition to 
     any tax imposed by subsection (a), pay a penalty in an amount 
     equal to such excess, plus interest at the underpayment rate 
     determined under section 6621 for the period beginning on the 
     due date for the payment of tax imposed by subsection (a) to 
     which the excess relates and ending on the date of payment of 
     the penalty.
       ``(2) Limitations on penalty.--
       ``(A) Penalty not to apply where failure not discovered 
     exercising reasonable diligence.--No penalty shall be imposed 
     by paragraph (1)(B) on any failure to properly calculate the 
     excess benefit during any period for which it is established 
     to the satisfaction of the Secretary that the employer or 
     plan sponsor neither knew, nor exercising reasonable 
     diligence would have known, that such failure existed.
       ``(B) Penalty not to apply to failures corrected within 30 
     days.--No penalty shall be imposed by paragraph (1)(B) on any 
     such failure if--
       ``(i) such failure was due to reasonable cause and not to 
     willful neglect, and
       ``(ii) such failure is corrected during the 30-day period 
     beginning on the 1st date that the employer knew, or 
     exercising reasonable diligence would have known, that such 
     failure existed.
       ``(C) Waiver by secretary.--In the case of any such failure 
     which is due to reasonable cause and not to willful neglect, 
     the Secretary may waive part or all of the penalty imposed by 
     paragraph (1), to the extent that the payment of such penalty 
     would be excessive or otherwise inequitable relative to the 
     failure involved.
       ``(f) Other Definitions and Special Rules.--For purposes of 
     this section--
       ``(1) Coverage determinations.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     an employee shall be treated as having self-only coverage 
     with respect to any applicable employer-sponsored coverage of 
     an employer.
       ``(B) Minimum essential coverage.--An employee shall be 
     treated as having coverage other than self-only coverage only 
     if the employee is enrolled in coverage other than self-only 
     coverage in a group health plan which provides minimum 
     essential coverage (as defined in section 5000A(f)) to the 
     employee and at least one other beneficiary, and the benefits 
     provided under such minimum essential coverage do not vary 
     based on whether any individual covered under such coverage 
     is the employee or another beneficiary.
       ``(2) Qualified retiree.--The term `qualified retiree' 
     means any individual who--
       ``(A) is receiving coverage by reason of being a retiree,
       ``(B) has attained age 55, and
       ``(C) is not entitled to benefits or eligible for 
     enrollment under the Medicare program under title XVIII of 
     the Social Security Act.
       ``(3) Employees engaged in high-risk profession.--The term 
     `employees engaged in a high-risk profession' means law 
     enforcement officers (as such term is defined in section 1204 
     of the Omnibus Crime Control and Safe Streets Act of 1968), 
     employees in fire protection activities (as such term is 
     defined in section 3(y) of the Fair Labor Standards Act of 
     1938), individuals who provide out-of-hospital emergency 
     medical care (including emergency medical technicians, 
     paramedics, and first-responders), and individuals engaged in 
     the construction, mining, agriculture (not including food 
     processing), forestry, and fishing industries. Such term 
     includes an employee who is retired from a high-risk 
     profession described in the preceding sentence, if such 
     employee satisfied the requirements of such sentence for a 
     period of not less than 20 years during the employee's 
     employment.
       ``(4) Group health plan.--The term `group health plan' has 
     the meaning given such term by section 5000(b)(1).
       ``(5) Health insurance coverage; health insurance issuer.--
       ``(A) Health insurance coverage.--The term `health 
     insurance coverage' has the meaning given such term by 
     section 9832(b)(1) (applied without regard to subparagraph 
     (B) thereof, except as provided by the Secretary in 
     regulations).
       ``(B) Health insurance issuer.--The term `health insurance 
     issuer' has the meaning given such term by section 
     9832(b)(2).
       ``(6) Person that administers the plan benefits.--The term 
     `person that administers the plan benefits' shall include the 
     plan sponsor if the plan sponsor administers benefits under 
     the plan.
       ``(7) Plan sponsor.--The term `plan sponsor' has the 
     meaning given such term in section 3(16)(B) of the Employee 
     Retirement Income Security Act of 1974.
       ``(8) Taxable period.--The term `taxable period' means the 
     calendar year or such shorter period as the Secretary may 
     prescribe. The Secretary may have different taxable periods 
     for employers of varying sizes.
       ``(9) Aggregation rules.--All employers treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414 shall be treated as a single employer.
       ``(10) Denial of deduction.--For denial of a deduction for 
     the tax imposed by this section, see section 275(a)(6).
       ``(g) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary to carry out this section.''.
       (b) Clerical Amendment.--The table of sections for chapter 
     43 of such Code, as amended by section 1513, is amended by 
     adding at the end the following new item:

``Sec. 4980I. Excise tax on high cost employer-sponsored health 
              coverage.''.

       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH 
                   COVERAGE ON W-2.

       (a) In General.--Section 6051(a) of the Internal Revenue 
     Code of 1986 (relating to receipts for employees) is amended 
     by striking ``and'' at the end of paragraph (12), by striking 
     the period at the end of paragraph (13) and inserting ``, 
     and'', and by adding after paragraph (13) the following new 
     paragraph:
       ``(14) the aggregate cost (determined under rules similar 
     to the rules of section 4980B(f)(4)) of applicable employer-
     sponsored coverage (as defined in section 4980I(d)(1)), 
     except that this paragraph shall not apply to--
       ``(A) coverage to which paragraphs (11) and (12) apply, or
       ``(B) the amount of any salary reduction contributions to a 
     flexible spending arrangement (within the meaning of section 
     125).''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

[[Page 4399]]



     SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR 
                   PRESCRIBED DRUG OR INSULIN.

       (a) HSAs.--Subparagraph (A) of section 223(d)(2) of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following: ``Such term shall include an amount paid for 
     medicine or a drug only if such medicine or drug is a 
     prescribed drug (determined without regard to whether such 
     drug is available without a prescription) or is insulin.''.
       (b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of 
     the Internal Revenue Code of 1986 is amended by adding at the 
     end the following: ``Such term shall include an amount paid 
     for medicine or a drug only if such medicine or drug is a 
     prescribed drug (determined without regard to whether such 
     drug is available without a prescription) or is insulin.''.
       (c) Health Flexible Spending Arrangements and Health 
     Reimbursement Arrangements.--Section 106 of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new subsection:
       ``(f) Reimbursements for Medicine Restricted to Prescribed 
     Drugs and Insulin.--For purposes of this section and section 
     105, reimbursement for expenses incurred for a medicine or a 
     drug shall be treated as a reimbursement for medical expenses 
     only if such medicine or drug is a prescribed drug 
     (determined without regard to whether such drug is available 
     without a prescription) or is insulin.''.
       (d) Effective Dates.--
       (1) Distributions from savings accounts.--The amendments 
     made by subsections (a) and (b) shall apply to amounts paid 
     with respect to taxable years beginning after December 31, 
     2010.
       (2) Reimbursements.--The amendment made by subsection (c) 
     shall apply to expenses incurred with respect to taxable 
     years beginning after December 31, 2010.

     SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM 
                   HSAS AND ARCHER MSAS NOT USED FOR QUALIFIED 
                   MEDICAL EXPENSES.

       (a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue 
     Code of 1986 is amended by striking ``10 percent'' and 
     inserting ``20 percent''.
       (b) Archer MSAs.--Section 220(f)(4)(A) of the Internal 
     Revenue Code of 1986 is amended by striking ``15 percent'' 
     and inserting ``20 percent''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to distributions made after December 31, 2010.

     SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING 
                   ARRANGEMENTS UNDER CAFETERIA PLANS.

       (a) In General.--Section 125 of the Internal Revenue Code 
     of 1986 is amended--
       (1) by redesignating subsections (i) and (j) as subsections 
     (j) and (k), respectively, and
       (2) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Limitation on Health Flexible Spending 
     Arrangements.--For purposes of this section, if a benefit is 
     provided under a cafeteria plan through employer 
     contributions to a health flexible spending arrangement, such 
     benefit shall not be treated as a qualified benefit unless 
     the cafeteria plan provides that an employee may not elect 
     for any taxable year to have salary reduction contributions 
     in excess of $2,500 made to such arrangement.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.

       (a) In General.--Section 6041 of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subsections:
       ``(h) Application to Corporations.--Notwithstanding any 
     regulation prescribed by the Secretary before the date of the 
     enactment of this subsection, for purposes of this section 
     the term `person' includes any corporation that is not an 
     organization exempt from tax under section 501(a).
       ``(i) Regulations.--The Secretary may prescribe such 
     regulations and other guidance as may be appropriate or 
     necessary to carry out the purposes of this section, 
     including rules to prevent duplicative reporting of 
     transactions.''.
       (b) Payments for Property and Other Gross Proceeds.--
     Subsection (a) of section 6041 of the Internal Revenue Code 
     of 1986 is amended--
       (1) by inserting ``amounts in consideration for property,'' 
     after ``wages,'',
       (2) by inserting ``gross proceeds,'' after ``emoluments, or 
     other'', and
       (3) by inserting ``gross proceeds,'' after ``setting forth 
     the amount of such''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to payments made after December 31, 2011.

     SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS.

       (a) Requirements To Qualify as Section 501(c)(3) Charitable 
     Hospital Organization.--Section 501 of the Internal Revenue 
     Code of 1986 (relating to exemption from tax on corporations, 
     certain trusts, etc.) is amended by redesignating subsection 
     (r) as subsection (s) and by inserting after subsection (q) 
     the following new subsection:
       ``(r) Additional Requirements for Certain Hospitals.--
       ``(1) In general.--A hospital organization to which this 
     subsection applies shall not be treated as described in 
     subsection (c)(3) unless the organization--
       ``(A) meets the community health needs assessment 
     requirements described in paragraph (3),
       ``(B) meets the financial assistance policy requirements 
     described in paragraph (4),
       ``(C) meets the requirements on charges described in 
     paragraph (5), and
       ``(D) meets the billing and collection requirement 
     described in paragraph (6).
       ``(2) Hospital organizations to which subsection applies.--
       ``(A) In general.--This subsection shall apply to--
       ``(i) an organization which operates a facility which is 
     required by a State to be licensed, registered, or similarly 
     recognized as a hospital, and
       ``(ii) any other organization which the Secretary 
     determines has the provision of hospital care as its 
     principal function or purpose constituting the basis for its 
     exemption under subsection (c)(3) (determined without regard 
     to this subsection).
       ``(B) Organizations with more than 1 hospital facility.--If 
     a hospital organization operates more than 1 hospital 
     facility--
       ``(i) the organization shall meet the requirements of this 
     subsection separately with respect to each such facility, and
       ``(ii) the organization shall not be treated as described 
     in subsection (c)(3) with respect to any such facility for 
     which such requirements are not separately met.
       ``(3) Community health needs assessments.--
       ``(A) In general.--An organization meets the requirements 
     of this paragraph with respect to any taxable year only if 
     the organization--
       ``(i) has conducted a community health needs assessment 
     which meets the requirements of subparagraph (B) in such 
     taxable year or in either of the 2 taxable years immediately 
     preceding such taxable year, and
       ``(ii) has adopted an implementation strategy to meet the 
     community health needs identified through such assessment.
       ``(B) Community health needs assessment.--A community 
     health needs assessment meets the requirements of this 
     paragraph if such community health needs assessment--
       ``(i) takes into account input from persons who represent 
     the broad interests of the community served by the hospital 
     facility, including those with special knowledge of or 
     expertise in public health, and
       ``(ii) is made widely available to the public.
       ``(4) Financial assistance policy.--An organization meets 
     the requirements of this paragraph if the organization 
     establishes the following policies:
       ``(A) Financial assistance policy.--A written financial 
     assistance policy which includes--
       ``(i) eligibility criteria for financial assistance, and 
     whether such assistance includes free or discounted care,
       ``(ii) the basis for calculating amounts charged to 
     patients,
       ``(iii) the method for applying for financial assistance,
       ``(iv) in the case of an organization which does not have a 
     separate billing and collections policy, the actions the 
     organization may take in the event of non-payment, including 
     collections action and reporting to credit agencies, and
       ``(v) measures to widely publicize the policy within the 
     community to be served by the organization.
       ``(B) Policy relating to emergency medical care.--A written 
     policy requiring the organization to provide, without 
     discrimination, care for emergency medical conditions (within 
     the meaning of section 1867 of the Social Security Act (42 
     U.S.C. 1395dd)) to individuals regardless of their 
     eligibility under the financial assistance policy described 
     in subparagraph (A).
       ``(5) Limitation on charges.--An organization meets the 
     requirements of this paragraph if the organization--
       ``(A) limits amounts charged for emergency or other 
     medically necessary care provided to individuals eligible for 
     assistance under the financial assistance policy described in 
     paragraph (4)(A) to not more than the lowest amounts charged 
     to individuals who have insurance covering such care, and
       ``(B) prohibits the use of gross charges.
       ``(6) Billing and collection requirements.--An organization 
     meets the requirement of this paragraph only if the 
     organization does not engage in extraordinary collection 
     actions before the organization has made reasonable efforts 
     to determine whether the individual is eligible for 
     assistance under the financial assistance policy described in 
     paragraph (4)(A).
       ``(7) Regulatory authority.--The Secretary shall issue such 
     regulations and guidance as may be necessary to carry out the 
     provisions of this subsection, including guidance relating to 
     what constitutes reasonable efforts to determine the 
     eligibility of a patient under a financial assistance policy 
     for purposes of paragraph (6).''.
       (b) Excise Tax for Failures To Meet Hospital Exemption 
     Requirements.--
       (1) In general.--Subchapter D of chapter 42 of the Internal 
     Revenue Code of 1986 (relating to failure by certain 
     charitable organizations to meet certain qualification 
     requirements) is amended by adding at the end the following 
     new section:

     ``SEC. 4959. TAXES ON FAILURES BY HOSPITAL ORGANIZATIONS.

       ``If a hospital organization to which section 501(r) 
     applies fails to meet the requirement of section 501(r)(3) 
     for any taxable year, there is imposed on the organization a 
     tax equal to $50,000.''.
       (2) Conforming amendment.--The table of sections for 
     subchapter D of chapter 42 of such Code is amended by adding 
     at the end the following new item:


[[Page 4400]]


``Sec. 4959. Taxes on failures by hospital organizations.''.
       (c) Mandatory Review of Tax Exemption for Hospitals.--The 
     Secretary of the Treasury or the Secretary's delegate shall 
     review at least once every 3 years the community benefit 
     activities of each hospital organization to which section 
     501(r) of the Internal Revenue Code of 1986 (as added by this 
     section) applies.
       (d) Additional Reporting Requirements.--
       (1) Community health needs assessments and audited 
     financial statements.--Section 6033(b) of the Internal 
     Revenue Code of 1986 (relating to certain organizations 
     described in section 501(c)(3)) is amended by striking 
     ``and'' at the end of paragraph (14), by redesignating 
     paragraph (15) as paragraph (16), and by inserting after 
     paragraph (14) the following new paragraph:
       ``(15) in the case of an organization to which the 
     requirements of section 501(r) apply for the taxable year--
       ``(A) a description of how the organization is addressing 
     the needs identified in each community health needs 
     assessment conducted under section 501(r)(3) and a 
     description of any such needs that are not being addressed 
     together with the reasons why such needs are not being 
     addressed, and
       ``(B) the audited financial statements of such organization 
     (or, in the case of an organization the financial statements 
     of which are included in a consolidated financial statement 
     with other organizations, such consolidated financial 
     statement).''.
       (2) Taxes.--Section 6033(b)(10) of such Code is amended by 
     striking ``and'' at the end of subparagraph (B), by inserting 
     ``and'' at the end of subparagraph (C), and by adding at the 
     end the following new subparagraph:
       ``(D) section 4959 (relating to taxes on failures by 
     hospital organizations),''.
       (e) Reports.--
       (1) Report on levels of charity care.--The Secretary of the 
     Treasury, in consultation with the Secretary of Health and 
     Human Services, shall submit to the Committees on Ways and 
     Means, Education and Labor, and Energy and Commerce of the 
     House of Representatives and to the Committees on Finance and 
     Health, Education, Labor, and Pensions of the Senate an 
     annual report on the following:
       (A) Information with respect to private tax-exempt, 
     taxable, and government-owned hospitals regarding--
       (i) levels of charity care provided,
       (ii) bad debt expenses,
       (iii) unreimbursed costs for services provided with respect 
     to means-tested government programs, and
       (iv) unreimbursed costs for services provided with respect 
     to non-means tested government programs.
       (B) Information with respect to private tax-exempt 
     hospitals regarding costs incurred for community benefit 
     activities.
       (2) Report on trends.--
       (A) Study.--The Secretary of the Treasury, in consultation 
     with the Secretary of Health and Human Services, shall 
     conduct a study on trends in the information required to be 
     reported under paragraph (1).
       (B) Report.--Not later than 5 years after the date of the 
     enactment of this Act, the Secretary of the Treasury, in 
     consultation with the Secretary of Health and Human Services, 
     shall submit a report on the study conducted under 
     subparagraph (A) to the Committees on Ways and Means, 
     Education and Labor, and Energy and Commerce of the House of 
     Representatives and to the Committees on Finance and Health, 
     Education, Labor, and Pensions of the Senate.
       (f) Effective Dates.--
       (1) In general.--Except as provided in paragraphs (2) and 
     (3), the amendments made by this section shall apply to 
     taxable years beginning after the date of the enactment of 
     this Act.
       (2) Community health needs assessment.--The requirements of 
     section 501(r)(3) of the Internal Revenue Code of 1986, as 
     added by subsection (a), shall apply to taxable years 
     beginning after the date which is 2 years after the date of 
     the enactment of this Act.
       (3) Excise tax.--The amendments made by subsection (b) 
     shall apply to failures occurring after the date of the 
     enactment of this Act.

     SEC. 9008. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION 
                   PHARMACEUTICAL MANUFACTURERS AND IMPORTERS.

       (a) Imposition of Fee.--
       (1) In general.--Each covered entity engaged in the 
     business of manufacturing or importing branded prescription 
     drugs shall pay to the Secretary of the Treasury not later 
     than the annual payment date of each calendar year beginning 
     after 2009 a fee in an amount determined under subsection 
     (b).
       (2) Annual payment date.--For purposes of this section, the 
     term ``annual payment date'' means with respect to any 
     calendar year the date determined by the Secretary, but in no 
     event later than September 30 of such calendar year.
       (b) Determination of Fee Amount.--
       (1) In general.--With respect to each covered entity, the 
     fee under this section for any calendar year shall be equal 
     to an amount that bears the same ratio to $2,300,000,000 as--
       (A) the covered entity's branded prescription drug sales 
     taken into account during the preceding calendar year, bear 
     to
       (B) the aggregate branded prescription drug sales of all 
     covered entities taken into account during such preceding 
     calendar year.
       (2) Sales taken into account.--For purposes of paragraph 
     (1), the branded prescription drug sales taken into account 
     during any calendar year with respect to any covered entity 
     shall be determined in accordance with the following table:


 
   With respect to a covered entity's
  aggregate branded prescription drug      The percentage of such sales
  sales during the calendar year that         taken into account is:
                  are:
 
  Not more than $5,000,000.............  0 percent
  More than $5,000,000 but not more      10 percent
   than $125,000,000.
  More than $125,000,000 but not more    40 percent
   than $225,000,000.
  More than $225,000,000 but not more    75 percent
   than $400,000,000.
  More than $400,000,000...............  100 percent.
 

       (3) Secretarial determination.--The Secretary of the 
     Treasury shall calculate the amount of each covered entity's 
     fee for any calendar year under paragraph (1). In calculating 
     such amount, the Secretary of the Treasury shall determine 
     such covered entity's branded prescription drug sales on the 
     basis of reports submitted under subsection (g) and through 
     the use of any other source of information available to the 
     Secretary of the Treasury.
       (c) Transfer of Fees to Medicare Part B Trust Fund.--There 
     is hereby appropriated to the Federal Supplementary Medical 
     Insurance Trust Fund established under section 1841 of the 
     Social Security Act an amount equal to the fees received by 
     the Secretary of the Treasury under subsection (a).
       (d) Covered Entity.--
       (1) In general.--For purposes of this section, the term 
     ``covered entity'' means any manufacturer or importer with 
     gross receipts from branded prescription drug sales.
       (2) Controlled groups.--
       (A) In general.--For purposes of this subsection, all 
     persons treated as a single employer under subsection (a) or 
     (b) of section 52 of the Internal Revenue Code of 1986 or 
     subsection (m) or (o) of section 414 of such Code shall be 
     treated as a single covered entity.
       (B) Inclusion of foreign corporations.--For purposes of 
     subparagraph (A), in applying subsections (a) and (b) of 
     section 52 of such Code to this section, section 1563 of such 
     Code shall be applied without regard to subsection (b)(2)(C) 
     thereof.
       (e) Branded Prescription Drug Sales.--For purposes of this 
     section--
       (1) In general.--The term ``branded prescription drug 
     sales'' means sales of branded prescription drugs to any 
     specified government program or pursuant to coverage under 
     any such program.
       (2) Branded prescription drugs.--
       (A) In general.--The term ``branded prescription drug'' 
     means--
       (i) any prescription drug the application for which was 
     submitted under section 505(b) of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355(b)), or
       (ii) any biological product the license for which was 
     submitted under section 351(a) of the Public Health Service 
     Act (42 U.S.C. 262(a)).
       (B) Prescription drug.--For purposes of subparagraph 
     (A)(i), the term ``prescription drug'' means any drug which 
     is subject to section 503(b) of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 353(b)).
       (3) Exclusion of orphan drug sales.--The term ``branded 
     prescription drug sales'' shall not include sales of any drug 
     or biological product with respect to which a credit was 
     allowed for any taxable year under section 45C of the 
     Internal Revenue Code of 1986. The preceding sentence shall 
     not apply with respect to any such drug or biological product 
     after the date on which such drug or biological product is 
     approved by the Food and Drug Administration for marketing 
     for any indication other than the treatment of the rare 
     disease or condition with respect to which such credit was 
     allowed.
       (4) Specified government program.--The term ``specified 
     government program'' means--
       (A) the Medicare Part D program under part D of title XVIII 
     of the Social Security Act,
       (B) the Medicare Part B program under part B of title XVIII 
     of the Social Security Act,
       (C) the Medicaid program under title XIX of the Social 
     Security Act,
       (D) any program under which branded prescription drugs are 
     procured by the Department of Veterans Affairs,
       (E) any program under which branded prescription drugs are 
     procured by the Department of Defense, or
       (F) the TRICARE retail pharmacy program under section 1074g 
     of title 10, United States Code.
       (f) Tax Treatment of Fees.--The fees imposed by this 
     section--
       (1) for purposes of subtitle F of the Internal Revenue Code 
     of 1986, shall be treated as excise taxes with respect to 
     which only civil actions for

[[Page 4401]]

     refund under procedures of such subtitle shall apply, and
       (2) for purposes of section 275 of such Code, shall be 
     considered to be a tax described in section 275(a)(6).
       (g) Reporting Requirement.--Not later than the date 
     determined by the Secretary of the Treasury following the end 
     of any calendar year, the Secretary of Health and Human 
     Services, the Secretary of Veterans Affairs, and the 
     Secretary of Defense shall report to the Secretary of the 
     Treasury, in such manner as the Secretary of the Treasury 
     prescribes, the total branded prescription drug sales for 
     each covered entity with respect to each specified government 
     program under such Secretary's jurisdiction using the 
     following methodology:
       (1) Medicare part d program.--The Secretary of Health and 
     Human Services shall report, for each covered entity and for 
     each branded prescription drug of the covered entity covered 
     by the Medicare Part D program, the product of--
       (A) the per-unit ingredient cost, as reported to the 
     Secretary of Health and Human Services by prescription drug 
     plans and Medicare Advantage prescription drug plans, minus 
     any per-unit rebate, discount, or other price concession 
     provided by the covered entity, as reported to the Secretary 
     of Health and Human Services by the prescription drug plans 
     and Medicare Advantage prescription drug plans, and
       (B) the number of units of the branded prescription drug 
     paid for under the Medicare Part D program.
       (2) Medicare part b program.--The Secretary of Health and 
     Human Services shall report, for each covered entity and for 
     each branded prescription drug of the covered entity covered 
     by the Medicare Part B program under section 1862(a) of the 
     Social Security Act, the product of--
       (A) the per-unit average sales price (as defined in section 
     1847A(c) of the Social Security Act) or the per-unit Part B 
     payment rate for a separately paid branded prescription drug 
     without a reported average sales price, and
       (B) the number of units of the branded prescription drug 
     paid for under the Medicare Part B program.
     The Centers for Medicare and Medicaid Services shall 
     establish a process for determining the units and the 
     allocated price for purposes of this section for those 
     branded prescription drugs that are not separately payable or 
     for which National Drug Codes are not reported.
       (3) Medicaid program.--The Secretary of Health and Human 
     Services shall report, for each covered entity and for each 
     branded prescription drug of the covered entity covered under 
     the Medicaid program, the product of--
       (A) the per-unit ingredient cost paid to pharmacies by 
     States for the branded prescription drug dispensed to 
     Medicaid beneficiaries, minus any per-unit rebate paid by the 
     covered entity under section 1927 of the Social Security Act 
     and any State supplemental rebate, and
       (B) the number of units of the branded prescription drug 
     paid for under the Medicaid program.
       (4) Department of veterans affairs programs.--The Secretary 
     of Veterans Affairs shall report, for each covered entity and 
     for each branded prescription drug of the covered entity the 
     total amount paid for each such branded prescription drug 
     procured by the Department of Veterans Affairs for its 
     beneficiaries.
       (5) Department of defense programs and tricare.--The 
     Secretary of Defense shall report, for each covered entity 
     and for each branded prescription drug of the covered entity, 
     the sum of--
       (A) the total amount paid for each such branded 
     prescription drug procured by the Department of Defense for 
     its beneficiaries, and
       (B) for each such branded prescription drug dispensed under 
     the TRICARE retail pharmacy program, the product of--
       (i) the per-unit ingredient cost, minus any per-unit rebate 
     paid by the covered entity, and
       (ii) the number of units of the branded prescription drug 
     dispensed under such program.
       (h) Secretary.--For purposes of this section, the term 
     ``Secretary'' includes the Secretary's delegate.
       (i) Guidance.--The Secretary of the Treasury shall publish 
     guidance necessary to carry out the purposes of this section.
       (j) Application of Section.--This section shall apply to 
     any branded prescription drug sales after December 31, 2008.
       (k) Conforming Amendment.--Section 1841(a) of the Social 
     Security Act is amended by inserting ``or section 9008(c) of 
     the Patient Protection and Affordable Care Act of 2009'' 
     after ``this part''.

     SEC. 9009. IMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE 
                   MANUFACTURERS AND IMPORTERS.

       (a) Imposition of Fee.--
       (1) In general.--Each covered entity engaged in the 
     business of manufacturing or importing medical devices shall 
     pay to the Secretary not later than the annual payment date 
     of each calendar year beginning after 2009 a fee in an amount 
     determined under subsection (b).
       (2) Annual payment date.--For purposes of this section, the 
     term ``annual payment date'' means with respect to any 
     calendar year the date determined by the Secretary, but in no 
     event later than September 30 of such calendar year.
       (b) Determination of Fee Amount.--
       (1) In general.--With respect to each covered entity, the 
     fee under this section for any calendar year shall be equal 
     to an amount that bears the same ratio to $2,000,000,000 as--
       (A) the covered entity's gross receipts from medical device 
     sales taken into account during the preceding calendar year, 
     bear to
       (B) the aggregate gross receipts of all covered entities 
     from medical device sales taken into account during such 
     preceding calendar year.
       (2) Gross receipts from sales taken into account.--For 
     purposes of paragraph (1), the gross receipts from medical 
     device sales taken into account during any calendar year with 
     respect to any covered entity shall be determined in 
     accordance with the following table:


 
   With respect to a covered entity's
 aggregate gross receipts from medical       The percentage of gross
 device sales during the calendar year   receipts taken into account is:
               that are:
 
  Not more than $5,000,000.............  0 percent
  More than $5,000,000 but not more      50 percent
   than $25,000,000.
  More than $25,000,000................  100 percent.
 

       (3) Secretarial determination.--The Secretary shall 
     calculate the amount of each covered entity's fee for any 
     calendar year under paragraph (1). In calculating such 
     amount, the Secretary shall determine such covered entity's 
     gross receipts from medical device sales on the basis of 
     reports submitted by the covered entity under subsection (f) 
     and through the use of any other source of information 
     available to the Secretary.
       (c) Covered Entity.--
       (1) In general.--For purposes of this section, the term 
     ``covered entity'' means any manufacturer or importer with 
     gross receipts from medical device sales.
       (2) Controlled groups.--
       (A) In general.--For purposes of this subsection, all 
     persons treated as a single employer under subsection (a) or 
     (b) of section 52 of the Internal Revenue Code of 1986 or 
     subsection (m) or (o) of section 414 of such Code shall be 
     treated as a single covered entity.
       (B) Inclusion of foreign corporations.--For purposes of 
     subparagraph (A), in applying subsections (a) and (b) of 
     section 52 of such Code to this section, section 1563 of such 
     Code shall be applied without regard to subsection (b)(2)(C) 
     thereof.
       (d) Medical Device Sales.--For purposes of this section--
       (1) In general.--The term ``medical device sales'' means 
     sales for use in the United States of any medical device, 
     other than the sales of a medical device that--
       (A) has been classified in class II under section 513 of 
     the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360c) and 
     is primarily sold to consumers at retail for not more than 
     $100 per unit, or
       (B) has been classified in class I under such section.
       (2) United states.--For purposes of paragraph (1), the term 
     ``United States'' means the several States, the District of 
     Columbia, the Commonwealth of Puerto Rico, and the 
     possessions of the United States.
       (3) Medical device.--For purposes of paragraph (1), the 
     term ``medical device'' means any device (as defined in 
     section 201(h) of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 321(h))) intended for humans.
       (e) Tax Treatment of Fees.--The fees imposed by this 
     section--
       (1) for purposes of subtitle F of the Internal Revenue Code 
     of 1986, shall be treated as excise taxes with respect to 
     which only civil actions for refund under procedures of such 
     subtitle shall apply, and
       (2) for purposes of section 275 of such Code, shall be 
     considered to be a tax described in section 275(a)(6).
       (f) Reporting Requirement.--
       (1) In general.--Not later than the date determined by the 
     Secretary following the end of any calendar year, each 
     covered entity shall report to the Secretary, in such manner 
     as the Secretary prescribes, the gross receipts from medical 
     device sales of such covered entity during such calendar 
     year.
       (2) Penalty for failure to report.--
       (A) In general.--In the case of any failure to make a 
     report containing the information required by paragraph (1) 
     on the date prescribed therefor (determined with regard to 
     any extension of time for filing), unless it is shown that 
     such failure is due to reasonable cause, there shall be paid 
     by the covered entity failing to file such report, an amount 
     equal to--
       (i) $10,000, plus
       (ii) the lesser of--

       (I) an amount equal to $1,000, multiplied by the number of 
     days during which such failure continues, or
       (II) the amount of the fee imposed by this section for 
     which such report was required.

[[Page 4402]]

       (B) Treatment of penalty.--The penalty imposed under 
     subparagraph (A)--
       (i) shall be treated as a penalty for purposes of subtitle 
     F of the Internal Revenue Code of 1986,
       (ii) shall be paid on notice and demand by the Secretary 
     and in the same manner as tax under such Code, and
       (iii) with respect to which only civil actions for refund 
     under procedures of such subtitle F shall apply.
       (g) Secretary.--For purposes of this section, the term 
     ``Secretary'' means the Secretary of the Treasury or the 
     Secretary's delegate.
       (h) Guidance.--The Secretary shall publish guidance 
     necessary to carry out the purposes of this section, 
     including identification of medical devices described in 
     subsection (d)(1)(A) and with respect to the treatment of 
     gross receipts from sales of medical devices to another 
     covered entity or to another entity by reason of the 
     application of subsection (c)(2).
       (i) Application of Section.--This section shall apply to 
     any medical device sales after December 31, 2008.

     SEC. 9010. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE 
                   PROVIDERS.

       (a) Imposition of Fee.--
       (1) In general.--Each covered entity engaged in the 
     business of providing health insurance shall pay to the 
     Secretary not later than the annual payment date of each 
     calendar year beginning after 2009 a fee in an amount 
     determined under subsection (b).
       (2) Annual payment date.--For purposes of this section, the 
     term ``annual payment date'' means with respect to any 
     calendar year the date determined by the Secretary, but in no 
     event later than September 30 of such calendar year.
       (b) Determination of Fee Amount.--
       (1) In general.--With respect to each covered entity, the 
     fee under this section for any calendar year shall be equal 
     to an amount that bears the same ratio to $6,700,000,000 as--
       (A) the sum of--
       (i) the covered entity's net premiums written with respect 
     to health insurance for any United States health risk that 
     are taken into account during the preceding calendar year, 
     plus
       (ii) 200 percent of the covered entity's third party 
     administration agreement fees that are taken into account 
     during the preceding calendar year, bears to
       (B) the sum of--
       (i) the aggregate net premiums written with respect to such 
     health insurance of all covered entities that are taken into 
     account during such preceding calendar year, plus
       (ii) 200 percent of the aggregate third party 
     administration agreement fees of all covered entities that 
     are taken into account during such preceding calendar year.
       (2) Amounts taken into account.--For purposes of paragraph 
     (1)--
       (A) Net premiums written.--The net premiums written with 
     respect to health insurance for any United States health risk 
     that are taken into account during any calendar year with 
     respect to any covered entity shall be determined in 
     accordance with the following table:


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

       (B) Third party administration agreement fees.--The third 
     party administration agreement fees that are taken into 
     account during any calendar year with respect to any covered 
     entity shall be determined in accordance with the following 
     table:


 
   With respect to a covered entity's     The percentage of third party
  third party administration agreement    administration agreement fees
fees during the calendar year that are:  that are taken into account is:
 
  Not more than $5,000,000.............  0 percent
  More than $5,000,000 but not more      50 percent
   than $10,000,000.
  More than $10,000,000................  100 percent.
 

       (3) Secretarial determination.--The Secretary shall 
     calculate the amount of each covered entity's fee for any 
     calendar year under paragraph (1). In calculating such 
     amount, the Secretary shall determine such covered entity's 
     net premiums written with respect to any United States health 
     risk and third party administration agreement fees on the 
     basis of reports submitted by the covered entity under 
     subsection (g) and through the use of any other source of 
     information available to the Secretary.
       (c) Covered Entity.--
       (1) In general.--For purposes of this section, the term 
     ``covered entity'' means any entity which provides health 
     insurance for any United States health risk.
       (2) Exclusion.--Such term does not include--
       (A) any employer to the extent that such employer self-
     insures its employees' health risks, or
       (B) any governmental entity (except to the extent such an 
     entity provides health insurance coverage through the 
     community health insurance option under section 1323).
       (3) Controlled groups.--
       (A) In general.--For purposes of this subsection, all 
     persons treated as a single employer under subsection (a) or 
     (b) of section 52 of the Internal Revenue Code of 1986 or 
     subsection (m) or (o) of section 414 of such Code shall be 
     treated as a single covered entity (or employer for purposes 
     of paragraph (2)).
       (B) Inclusion of foreign corporations.--For purposes of 
     subparagraph (A), in applying subsections (a) and (b) of 
     section 52 of such Code to this section, section 1563 of such 
     Code shall be applied without regard to subsection (b)(2)(C) 
     thereof.
       (d) United States Health Risk.--For purposes of this 
     section, the term ``United States health risk'' means the 
     health risk of any individual who is--
       (1) a United States citizen,
       (2) a resident of the United States (within the meaning of 
     section 7701(b)(1)(A) of the Internal Revenue Code of 1986), 
     or
       (3) located in the United States, with respect to the 
     period such individual is so located.
       (e) Third Party Administration Agreement Fees.--For 
     purposes of this section, the term ``third party 
     administration agreement fees'' means, with respect to any 
     covered entity, amounts received from an employer which are 
     in excess of payments made by such covered entity for health 
     benefits under an arrangement under which such employer self-
     insures the United States health risk of its employees.
       (f) Tax Treatment of Fees.--The fees imposed by this 
     section--
       (1) for purposes of subtitle F of the Internal Revenue Code 
     of 1986, shall be treated as excise taxes with respect to 
     which only civil actions for refund under procedures of such 
     subtitle shall apply, and
       (2) for purposes of section 275 of such Code shall be 
     considered to be a tax described in section 275(a)(6).
       (g) Reporting Requirement.--
       (1) In general.--Not later than the date determined by the 
     Secretary following the end of any calendar year, each 
     covered entity shall report to the Secretary, in such manner 
     as the Secretary prescribes, the covered entity's net 
     premiums written with respect to health insurance for any 
     United States health risk and third party administration 
     agreement fees for such calendar year.
       (2) Penalty for failure to report.--
       (A) In general.--In the case of any failure to make a 
     report containing the information required by paragraph (1) 
     on the date prescribed therefor (determined with regard to 
     any extension of time for filing), unless it is shown that 
     such failure is due to reasonable cause, there shall be paid 
     by the covered entity failing to file such report, an amount 
     equal to--
       (i) $10,000, plus
       (ii) the lesser of--

       (I) an amount equal to $1,000, multiplied by the number of 
     days during which such failure continues, or
       (II) the amount of the fee imposed by this section for 
     which such report was required.

       (B) Treatment of penalty.--The penalty imposed under 
     subparagraph (A)--
       (i) shall be treated as a penalty for purposes of subtitle 
     F of the Internal Revenue Code of 1986,
       (ii) shall be paid on notice and demand by the Secretary 
     and in the same manner as tax under such Code, and
       (iii) with respect to which only civil actions for refund 
     under procedures of such subtitle F shall apply.
       (h) Additional Definitions.--For purposes of this section--
       (1) Secretary.--The term ``Secretary'' means the Secretary 
     of the Treasury or the Secretary's delegate.
       (2) United states.--The term ``United States'' means the 
     several States, the District of Columbia, the Commonwealth of 
     Puerto Rico, and the possessions of the United States.
       (3) Health insurance.--The term ``health insurance'' shall 
     not include insurance for long-term care or disability.
       (i) Guidance.--The Secretary shall publish guidance 
     necessary to carry out the purposes of this section.
       (j) Application of Section.--This section shall apply to 
     any net premiums written after

[[Page 4403]]

     December 31, 2008, with respect to health insurance for any 
     United States health risk, and any third party administration 
     agreement fees received after such date.

     SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH 
                   CARE.

       (a) In General.--The Secretary of Veterans Affairs shall 
     conduct a study on the effect (if any) of the provisions of 
     sections 9008, 9009, and 9010 on--
       (1) the cost of medical care provided to veterans, and
       (2) veterans' access to medical devices and branded 
     prescription drugs.
       (b) Report.--The Secretary of Veterans Affairs shall report 
     the results of the study under subsection (a) to the 
     Committee on Ways and Means of the House of Representatives 
     and to the Committee on Finance of the Senate not later than 
     December 31, 2012.

     SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE TO 
                   MEDICARE PART D SUBSIDY.

       (a) In General.--Section 139A of the Internal Revenue Code 
     of 1986 is amended by striking the second sentence.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL 
                   EXPENSES.

       (a) In General.--Subsection (a) of section 213 of the 
     Internal Revenue Code of 1986 is amended by striking ``7.5 
     percent'' and inserting ``10 percent''.
       (b) Temporary Waiver of Increase for Certain Seniors.--
     Section 213 of the Internal Revenue Code of 1986 is amended 
     by adding at the end the following new subsection:
       ``(f) Special Rule for 2013, 2014, 2015, and 2016.--In the 
     case of any taxable year beginning after December 31, 2012, 
     and ending before January 1, 2017, subsection (a) shall be 
     applied with respect to a taxpayer by substituting `7.5 
     percent' for `10 percent' if such taxpayer or such taxpayer's 
     spouse has attained age 65 before the close of such taxable 
     year.''.
       (c) Conforming Amendment.--Section 56(b)(1)(B) of the 
     Internal Revenue Code of 1986 is amended by striking ``by 
     substituting `10 percent' for `7.5 percent''' and inserting 
     ``without regard to subsection (f) of such section''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY 
                   CERTAIN HEALTH INSURANCE PROVIDERS.

       (a) In General.--Section 162(m) of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following 
     new subparagraph:
       ``(6) Special rule for application to certain health 
     insurance providers.--
       ``(A) In general.--No deduction shall be allowed under this 
     chapter--
       ``(i) in the case of applicable individual remuneration 
     which is for any disqualified taxable year beginning after 
     December 31, 2012, and which is attributable to services 
     performed by an applicable individual during such taxable 
     year, to the extent that the amount of such remuneration 
     exceeds $500,000, or
       ``(ii) in the case of deferred deduction remuneration for 
     any taxable year beginning after December 31, 2012, which is 
     attributable to services performed by an applicable 
     individual during any disqualified taxable year beginning 
     after December 31, 2009, to the extent that the amount of 
     such remuneration exceeds $500,000 reduced (but not below 
     zero) by the sum of--

       ``(I) the applicable individual remuneration for such 
     disqualified taxable year, plus
       ``(II) the portion of the deferred deduction remuneration 
     for such services which was taken into account under this 
     clause in a preceding taxable year (or which would have been 
     taken into account under this clause in a preceding taxable 
     year if this clause were applied by substituting `December 
     31, 2009' for `December 31, 2012' in the matter preceding 
     subclause (I)).

       ``(B) Disqualified taxable year.--For purposes of this 
     paragraph, the term `disqualified taxable year' means, with 
     respect to any employer, any taxable year for which such 
     employer is a covered health insurance provider.
       ``(C) Covered health insurance provider.--For purposes of 
     this paragraph--
       ``(i) In general.--The term `covered health insurance 
     provider' means--

       ``(I) with respect to taxable years beginning after 
     December 31, 2009, and before January 1, 2013, any employer 
     which is a health insurance issuer (as defined in section 
     9832(b)(2)) and which receives premiums from providing health 
     insurance coverage (as defined in section 9832(b)(1)), and
       ``(II) with respect to taxable years beginning after 
     December 31, 2012, any employer which is a health insurance 
     issuer (as defined in section 9832(b)(2)) and with respect to 
     which not less than 25 percent of the gross premiums received 
     from providing health insurance coverage (as defined in 
     section 9832(b)(1)) is from minimum essential coverage (as 
     defined in section 5000A(f)).

       ``(ii) Aggregation rules.--Two or more persons who are 
     treated as a single employer under subsection (b), (c), (m), 
     or (o) of section 414 shall be treated as a single employer, 
     except that in applying section 1563(a) for purposes of any 
     such subsection, paragraphs (2) and (3) thereof shall be 
     disregarded.
       ``(D) Applicable individual remuneration.--For purposes of 
     this paragraph, the term `applicable individual remuneration' 
     means, with respect to any applicable individual for any 
     disqualified taxable year, the aggregate amount allowable as 
     a deduction under this chapter for such taxable year 
     (determined without regard to this subsection) for 
     remuneration (as defined in paragraph (4) without regard to 
     subparagraphs (B), (C), and (D) thereof) for services 
     performed by such individual (whether or not during the 
     taxable year). Such term shall not include any deferred 
     deduction remuneration with respect to services performed 
     during the disqualified taxable year.
       ``(E) Deferred deduction remuneration.--For purposes of 
     this paragraph, the term `deferred deduction remuneration' 
     means remuneration which would be applicable individual 
     remuneration for services performed in a disqualified taxable 
     year but for the fact that the deduction under this chapter 
     (determined without regard to this paragraph) for such 
     remuneration is allowable in a subsequent taxable year.
       ``(F) Applicable individual.--For purposes of this 
     paragraph, the term `applicable individual' means, with 
     respect to any covered health insurance provider for any 
     disqualified taxable year, any individual--
       ``(i) who is an officer, director, or employee in such 
     taxable year, or
       ``(ii) who provides services for or on behalf of such 
     covered health insurance provider during such taxable year.
       ``(G) Coordination.--Rules similar to the rules of 
     subparagraphs (F) and (G) of paragraph (4) shall apply for 
     purposes of this paragraph.
       ``(H) Regulatory authority.--The Secretary may prescribe 
     such guidance, rules, or regulations as are necessary to 
     carry out the purposes of this paragraph.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2009, with respect to services performed after such date.

     SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME 
                   TAXPAYERS.

       (a) FICA.--
       (1) In general.--Section 3101(b) of the Internal Revenue 
     Code of 1986 is amended--
       (A) by striking ``In addition'' and inserting the 
     following:
       ``(1) In general.--In addition'',
       (B) by striking ``the following percentages of the'' and 
     inserting ``1.45 percent of the'',
       (C) by striking ``(as defined in section 3121(b))--'' and 
     all that follows and inserting ``(as defined in section 
     3121(b)).'', and
       (D) by adding at the end the following new paragraph:
       ``(2) Additional tax.--In addition to the tax imposed by 
     paragraph (1) and the preceding subsection, there is hereby 
     imposed on every taxpayer (other than a corporation, estate, 
     or trust) a tax equal to 0.5 percent of wages which are 
     received with respect to employment (as defined in section 
     3121(b)) during any taxable year beginning after December 31, 
     2012, and which are in excess of--
       ``(A) in the case of a joint return, $250,000, and
       ``(B) in any other case, $200,000.''.
       (2) Collection of tax.--Section 3102 of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new subsection:
       ``(f) Special Rules for Additional Tax.--
       ``(1) In general.--In the case of any tax imposed by 
     section 3101(b)(2), subsection (a) shall only apply to the 
     extent to which the taxpayer receives wages from the employer 
     in excess of $200,000, and the employer may disregard the 
     amount of wages received by such taxpayer's spouse.
       ``(2) Collection of amounts not withheld.--To the extent 
     that the amount of any tax imposed by section 3101(b)(2) is 
     not collected by the employer, such tax shall be paid by the 
     employee.
       ``(3) Tax paid by recipient.--If an employer, in violation 
     of this chapter, fails to deduct and withhold the tax imposed 
     by section 3101(b)(2) and thereafter the tax is paid by the 
     employee, the tax so required to be deducted and withheld 
     shall not be collected from the employer, but this paragraph 
     shall in no case relieve the employer from liability for any 
     penalties or additions to tax otherwise applicable in respect 
     of such failure to deduct and withhold.''.
       (b) SECA.--
       (1) In general.--Section 1401(b) of the Internal Revenue 
     Code of 1986 is amended--
       (A) by striking ``In addition'' and inserting the 
     following:
       ``(1) In general.--In addition'', and
       (B) by adding at the end the following new paragraph:
       ``(2) Additional tax.--
       ``(A) In general.--In addition to the tax imposed by 
     paragraph (1) and the preceding subsection, there is hereby 
     imposed on every taxpayer (other than a corporation, estate, 
     or trust) for each taxable year beginning after December 31, 
     2012, a tax equal to 0.5 percent of the self-employment 
     income for such taxable year which is in excess of--
       ``(i) in the case of a joint return, $250,000, and
       ``(ii) in any other case, $200,000.
       ``(B) Coordination with fica.--The amounts under clauses 
     (i) and (ii) of subparagraph (A) shall be reduced (but not 
     below zero) by the amount of wages taken into account in 
     determining the tax imposed under section 3121(b)(2) with 
     respect to the taxpayer.''.
       (2) No deduction for additional tax.--
       (A) In general.--Section 164(f) of such Code is amended by 
     inserting ``(other than the taxes imposed by section 
     1401(b)(2))'' after ``section 1401)''.
       (B) Deduction for net earnings from self-employment.--
     Subparagraph (B) of section

[[Page 4404]]

     1402(a)(12) is amended by inserting ``(determined without 
     regard to the rate imposed under paragraph (2) of section 
     1401(b))'' after ``for such year''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to remuneration received, and 
     taxable years beginning, after December 31, 2012.

     SEC. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN 
                   HEALTH ORGANIZATIONS.

       (a) In General.--Subsection (c) of section 833 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new paragraph:
       ``(5) Nonapplication of section in case of low medical loss 
     ratio.--Notwithstanding the preceding paragraphs, this 
     section shall not apply to any organization unless such 
     organization's percentage of total premium revenue expended 
     on reimbursement for clinical services provided to enrollees 
     under its policies during such taxable year (as reported 
     under section 2718 of the Public Health Service Act) is not 
     less than 85 percent.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2009.

     SEC. 9017. EXCISE TAX ON ELECTIVE COSMETIC MEDICAL 
                   PROCEDURES.

       (a) In General.--Subtitle D of the Internal Revenue Code of 
     1986, as amended by this Act, is amended by adding at the end 
     the following new chapter:

           ``CHAPTER 49--ELECTIVE COSMETIC MEDICAL PROCEDURES

``Sec. 5000B. Imposition of tax on elective cosmetic medical 
              procedures.

     ``SEC. 5000B. IMPOSITION OF TAX ON ELECTIVE COSMETIC MEDICAL 
                   PROCEDURES.

       ``(a) In General.--There is hereby imposed on any cosmetic 
     surgery and medical procedure a tax equal to 5 percent of the 
     amount paid for such procedure (determined without regard to 
     this section), whether paid by insurance or otherwise.
       ``(b) Cosmetic Surgery and Medical Procedure.--For purposes 
     of this section, the term `cosmetic surgery and medical 
     procedure' means any cosmetic surgery (as defined in section 
     213(d)(9)(B)) or other similar procedure which--
       ``(1) is performed by a licensed medical professional, and
       ``(2) is not necessary to ameliorate a deformity arising 
     from, or directly related to, a congenital abnormality, a 
     personal injury resulting from an accident or trauma, or 
     disfiguring disease.
       ``(c) Payment of Tax.--
       ``(1) In general.--The tax imposed by this section shall be 
     paid by the individual on whom the procedure is performed.
       ``(2) Collection.--Every person receiving a payment for 
     procedures on which a tax is imposed under subsection (a) 
     shall collect the amount of the tax from the individual on 
     whom the procedure is performed and remit such tax quarterly 
     to the Secretary at such time and in such manner as provided 
     by the Secretary.
       ``(3) Secondary liability.--Where any tax imposed by 
     subsection (a) is not paid at the time payments for cosmetic 
     surgery and medical procedures are made, then to the extent 
     that such tax is not collected, such tax shall be paid by the 
     person who performs the procedure.''.
       (b) Clerical Amendment.--The table of chapters for subtitle 
     D of the Internal Revenue Code of 1986, as amended by this 
     Act, is amended by inserting after the item relating to 
     chapter 48 the following new item:

         ``Chapter 49--Elective Cosmetic Medical Procedures''.

       (c) Effective Date.--The amendments made by this section 
     shall apply to procedures performed on or after January 1, 
     2010.

                      Subtitle B--Other Provisions

     SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN 
                   TRIBAL GOVERNMENTS.

       (a) In General.--Part III of subchapter B of chapter 1 of 
     the Internal Revenue Code of 1986 is amended by inserting 
     after section 139C the following new section:

     ``SEC. 139D. INDIAN HEALTH CARE BENEFITS.

       ``(a) General Rule.--Except as otherwise provided in this 
     section, gross income does not include the value of any 
     qualified Indian health care benefit.
       ``(b) Qualified Indian Health Care Benefit.--For purposes 
     of this section, the term `qualified Indian health care 
     benefit' means--
       ``(1) any health service or benefit provided or purchased, 
     directly or indirectly, by the Indian Health Service through 
     a grant to or a contract or compact with an Indian tribe or 
     tribal organization, or through a third-party program funded 
     by the Indian Health Service,
       ``(2) medical care provided or purchased by, or amounts to 
     reimburse for such medical care provided by, an Indian tribe 
     or tribal organization for, or to, a member of an Indian 
     tribe, including a spouse or dependent of such a member,
       ``(3) coverage under accident or health insurance (or an 
     arrangement having the effect of accident or health 
     insurance), or an accident or health plan, provided by an 
     Indian tribe or tribal organization for medical care to a 
     member of an Indian tribe, include a spouse or dependent of 
     such a member, and
       ``(4) any other medical care provided by an Indian tribe or 
     tribal organization that supplements, replaces, or 
     substitutes for a program or service relating to medical care 
     provided by the Federal government to Indian tribes or 
     members of such a tribe.
       ``(c) Definitions.--For purposes of this section--
       ``(1) Indian tribe.--The term `Indian tribe' has the 
     meaning given such term by section 45A(c)(6).
       ``(2) Tribal organization.--The term `tribal organization' 
     has the meaning given such term by section 4(l) of the Indian 
     Self-Determination and Education Assistance Act.
       ``(3) Medical care.--The term `medical care' has the same 
     meaning as when used in section 213.
       ``(4) Accident or health insurance; accident or health 
     plan.--The terms `accident or health insurance' and `accident 
     or health plan' have the same meaning as when used in section 
     105.
       ``(5) Dependent.--The term `dependent' has the meaning 
     given such term by section 152, determined without regard to 
     subsections (b)(1), (b)(2), and (d)(1)(B) thereof.
       ``(d) Denial of Double Benefit.--Subsection (a) shall not 
     apply to the amount of any qualified Indian health care 
     benefit which is not includible in gross income of the 
     beneficiary of such benefit under any other provision of this 
     chapter, or to the amount of any such benefit for which a 
     deduction is allowed to such beneficiary under any other 
     provision of this chapter.''.
       (b) Clerical Amendment.--The table of sections for part III 
     of subchapter B of chapter 1 of the Internal Revenue Code of 
     1986 is amended by inserting after the item relating to 
     section 139C the following new item:

``Sec. 139D. Indian health care benefits.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to benefits and coverage provided after the date 
     of the enactment of this Act.
       (d) No Inference.--Nothing in the amendments made by this 
     section shall be construed to create an inference with 
     respect to the exclusion from gross income of--
       (1) benefits provided by an Indian tribe or tribal 
     organization that are not within the scope of this section, 
     and
       (2) benefits provided prior to the date of the enactment of 
     this Act.

     SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL 
                   BUSINESSES.

       (a) In General.--Section 125 of the Internal Revenue Code 
     of 1986 (relating to cafeteria plans), as amended by this 
     Act, is amended by redesignating subsections (j) and (k) as 
     subsections (k) and (l), respectively, and by inserting after 
     subsection (i) the following new subsection:
       ``(j) Simple Cafeteria Plans for Small Businesses.--
       ``(1) In general.--An eligible employer maintaining a 
     simple cafeteria plan with respect to which the requirements 
     of this subsection are met for any year shall be treated as 
     meeting any applicable nondiscrimination requirement during 
     such year.
       ``(2) Simple cafeteria plan.--For purposes of this 
     subsection, the term `simple cafeteria plan' means a 
     cafeteria plan--
       ``(A) which is established and maintained by an eligible 
     employer, and
       ``(B) with respect to which the contribution requirements 
     of paragraph (3), and the eligibility and participation 
     requirements of paragraph (4), are met.
       ``(3) Contribution requirements.--
       ``(A) In general.--The requirements of this paragraph are 
     met if, under the plan the employer is required, without 
     regard to whether a qualified employee makes any salary 
     reduction contribution, to make a contribution to provide 
     qualified benefits under the plan on behalf of each qualified 
     employee in an amount equal to--
       ``(i) a uniform percentage (not less than 2 percent) of the 
     employee's compensation for the plan year, or
       ``(ii) an amount which is not less than the lesser of--

       ``(I) 6 percent of the employee's compensation for the plan 
     year, or
       ``(II) twice the amount of the salary reduction 
     contributions of each qualified employee.

       ``(B) Matching contributions on behalf of highly 
     compensated and key employees.--The requirements of 
     subparagraph (A)(ii) shall not be treated as met if, under 
     the plan, the rate of contributions with respect to any 
     salary reduction contribution of a highly compensated or key 
     employee at any rate of contribution is greater than that 
     with respect to an employee who is not a highly compensated 
     or key employee.
       ``(C) Additional contributions.--Subject to subparagraph 
     (B), nothing in this paragraph shall be treated as 
     prohibiting an employer from making contributions to provide 
     qualified benefits under the plan in addition to 
     contributions required under subparagraph (A).
       ``(D) Definitions.--For purposes of this paragraph--
       ``(i) Salary reduction contribution.--The term `salary 
     reduction contribution' means, with respect to a cafeteria 
     plan, any amount which is contributed to the plan at the 
     election of the employee and which is not includible in gross 
     income by reason of this section.
       ``(ii) Qualified employee.--The term `qualified employee' 
     means, with respect to a cafeteria plan, any employee who is 
     not a highly compensated or key employee and who is eligible 
     to participate in the plan.
       ``(iii) Highly compensated employee.--The term `highly 
     compensated employee' has the meaning given such term by 
     section 414(q).
       ``(iv) Key employee.--The term `key employee' has the 
     meaning given such term by section 416(i).

[[Page 4405]]

       ``(4) Minimum eligibility and participation requirements.--
       ``(A) In general.--The requirements of this paragraph shall 
     be treated as met with respect to any year if, under the 
     plan--
       ``(i) all employees who had at least 1,000 hours of service 
     for the preceding plan year are eligible to participate, and
       ``(ii) each employee eligible to participate in the plan 
     may, subject to terms and conditions applicable to all 
     participants, elect any benefit available under the plan.
       ``(B) Certain employees may be excluded.--For purposes of 
     subparagraph (A)(i), an employer may elect to exclude under 
     the plan employees--
       ``(i) who have not attained the age of 21 before the close 
     of a plan year,
       ``(ii) who have less than 1 year of service with the 
     employer as of any day during the plan year,
       ``(iii) who are covered under an agreement which the 
     Secretary of Labor finds to be a collective bargaining 
     agreement if there is evidence that the benefits covered 
     under the cafeteria plan were the subject of good faith 
     bargaining between employee representatives and the employer, 
     or
       ``(iv) who are described in section 410(b)(3)(C) (relating 
     to nonresident aliens working outside the United States).

     A plan may provide a shorter period of service or younger age 
     for purposes of clause (i) or (ii).
       ``(5) Eligible employer.--For purposes of this subsection--
       ``(A) In general.--The term `eligible employer' means, with 
     respect to any year, any employer if such employer employed 
     an average of 100 or fewer employees on business days during 
     either of the 2 preceding years. For purposes of this 
     subparagraph, a year may only be taken into account if the 
     employer was in existence throughout the year.
       ``(B) Employers not in existence during preceding year.--If 
     an employer was not in existence throughout the preceding 
     year, the determination under subparagraph (A) shall be based 
     on the average number of employees that it is reasonably 
     expected such employer will employ on business days in the 
     current year.
       ``(C) Growing employers retain treatment as small 
     employer.--
       ``(i) In general.--If--

       ``(I) an employer was an eligible employer for any year (a 
     `qualified year'), and
       ``(II) such employer establishes a simple cafeteria plan 
     for its employees for such year,

     then, notwithstanding the fact the employer fails to meet the 
     requirements of subparagraph (A) for any subsequent year, 
     such employer shall be treated as an eligible employer for 
     such subsequent year with respect to employees (whether or 
     not employees during a qualified year) of any trade or 
     business which was covered by the plan during any qualified 
     year.
       ``(ii) Exception.--This subparagraph shall cease to apply 
     if the employer employs an average of 200 or more employees 
     on business days during any year preceding any such 
     subsequent year.
       ``(D) Special rules.--
       ``(i) Predecessors.--Any reference in this paragraph to an 
     employer shall include a reference to any predecessor of such 
     employer.
       ``(ii) Aggregation rules.--All persons treated as a single 
     employer under subsection (a) or (b) of section 52, or 
     subsection (n) or (o) of section 414, shall be treated as one 
     person.
       ``(6) Applicable nondiscrimination requirement.--For 
     purposes of this subsection, the term `applicable 
     nondiscrimination requirement' means any requirement under 
     subsection (b) of this section, section 79(d), section 
     105(h), or paragraph (2), (3), (4), or (8) of section 129(d).
       ``(7) Compensation.--The term `compensation' has the 
     meaning given such term by section 414(s).''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to years beginning after December 31, 2010.

     SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.

       (a) In General.--Subpart E of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 is amended by 
     inserting after section 48C the following new section:

     ``SEC. 48D. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT.

       ``(a) In General.--For purposes of section 46, the 
     qualifying therapeutic discovery project credit for any 
     taxable year is an amount equal to 50 percent of the 
     qualified investment for such taxable year with respect to 
     any qualifying therapeutic discovery project of an eligible 
     taxpayer.
       ``(b) Qualified Investment.--
       ``(1) In general.--For purposes of subsection (a), the 
     qualified investment for any taxable year is the aggregate 
     amount of the costs paid or incurred in such taxable year for 
     expenses necessary for and directly related to the conduct of 
     a qualifying therapeutic discovery project.
       ``(2) Limitation.--The amount which is treated as qualified 
     investment for all taxable years with respect to any 
     qualifying therapeutic discovery project shall not exceed the 
     amount certified by the Secretary as eligible for the credit 
     under this section.
       ``(3) Exclusions.--The qualified investment for any taxable 
     year with respect to any qualifying therapeutic discovery 
     project shall not take into account any cost--
       ``(A) for remuneration for an employee described in section 
     162(m)(3),
       ``(B) for interest expenses,
       ``(C) for facility maintenance expenses,
       ``(D) which is identified as a service cost under section 
     1.263A-1(e)(4) of title 26, Code of Federal Regulations, or
       ``(E) for any other expense as determined by the Secretary 
     as appropriate to carry out the purposes of this section.
       ``(4) Certain progress expenditure rules made applicable.--
     In the case of costs described in paragraph (1) that are paid 
     for property of a character subject to an allowance for 
     depreciation, rules similar to the rules of subsections 
     (c)(4) and (d) of section 46 (as in effect on the day before 
     the date of the enactment of the Revenue Reconciliation Act 
     of 1990) shall apply for purposes of this section.
       ``(5) Application of subsection.--An investment shall be 
     considered a qualified investment under this subsection only 
     if such investment is made in a taxable year beginning in 
     2009 or 2010.
       ``(c) Definitions.--
       ``(1) Qualifying therapeutic discovery project.--The term 
     `qualifying therapeutic discovery project' means a project 
     which is designed--
       ``(A) to treat or prevent diseases or conditions by 
     conducting pre-clinical activities, clinical trials, and 
     clinical studies, or carrying out research protocols, for the 
     purpose of securing approval of a product under section 
     505(b) of the Federal Food, Drug, and Cosmetic Act or section 
     351(a) of the Public Health Service Act,
       ``(B) to diagnose diseases or conditions or to determine 
     molecular factors related to diseases or conditions by 
     developing molecular diagnostics to guide therapeutic 
     decisions, or
       ``(C) to develop a product, process, or technology to 
     further the delivery or administration of therapeutics.
       ``(2) Eligible taxpayer.--
       ``(A) In general.--The term `eligible taxpayer' means a 
     taxpayer which employs not more than 250 employees in all 
     businesses of the taxpayer at the time of the submission of 
     the application under subsection (d)(2).
       ``(B) Aggregation rules.--All persons treated as a single 
     employer under subsection (a) or (b) of section 52, or 
     subsection (m) or (o) of section 414, shall be so treated for 
     purposes of this paragraph.
       ``(3) Facility maintenance expenses.--The term `facility 
     maintenance expenses' means costs paid or incurred to 
     maintain a facility, including--
       ``(A) mortgage or rent payments,
       ``(B) insurance payments,
       ``(C) utility and maintenance costs, and
       ``(D) costs of employment of maintenance personnel.
       ``(d) Qualifying Therapeutic Discovery Project Program.--
       ``(1) Establishment.--
       ``(A) In general.--Not later than 60 days after the date of 
     the enactment of this section, the Secretary, in consultation 
     with the Secretary of Health and Human Services, shall 
     establish a qualifying therapeutic discovery project program 
     to consider and award certifications for qualified 
     investments eligible for credits under this section to 
     qualifying therapeutic discovery project sponsors.
       ``(B) Limitation.--The total amount of credits that may be 
     allocated under the program shall not exceed $1,000,000,000 
     for the 2-year period beginning with 2009.
       ``(2) Certification.--
       ``(A) Application period.--Each applicant for certification 
     under this paragraph shall submit an application containing 
     such information as the Secretary may require during the 
     period beginning on the date the Secretary establishes the 
     program under paragraph (1).
       ``(B) Time for review of applications.--The Secretary shall 
     take action to approve or deny any application under 
     subparagraph (A) within 30 days of the submission of such 
     application.
       ``(C) Multi-year applications.--An application for 
     certification under subparagraph (A) may include a request 
     for an allocation of credits for more than 1 of the years 
     described in paragraph (1)(B).
       ``(3) Selection criteria.--In determining the qualifying 
     therapeutic discovery projects with respect to which 
     qualified investments may be certified under this section, 
     the Secretary--
       ``(A) shall take into consideration only those projects 
     that show reasonable potential--
       ``(i) to result in new therapies--

       ``(I) to treat areas of unmet medical need, or
       ``(II) to prevent, detect, or treat chronic or acute 
     diseases and conditions,

       ``(ii) to reduce long-term health care costs in the United 
     States, or
       ``(iii) to significantly advance the goal of curing cancer 
     within the 30-year period beginning on the date the Secretary 
     establishes the program under paragraph (1), and
       ``(B) shall take into consideration which projects have the 
     greatest potential--
       ``(i) to create and sustain (directly or indirectly) high 
     quality, high-paying jobs in the United States, and
       ``(ii) to advance United States competitiveness in the 
     fields of life, biological, and medical sciences.
       ``(4) Disclosure of allocations.--The Secretary shall, upon 
     making a certification under this subsection, publicly 
     disclose the identity of the applicant and the amount of the 
     credit with respect to such applicant.
       ``(e) Special Rules.--
       ``(1) Basis adjustment.--For purposes of this subtitle, if 
     a credit is allowed under this section for an expenditure 
     related to property of a character subject to an allowance 
     for depreciation, the basis of such property shall be reduced 
     by the amount of such credit.

[[Page 4406]]

       ``(2) Denial of double benefit.--
       ``(A) Bonus depreciation.--A credit shall not be allowed 
     under this section for any investment for which bonus 
     depreciation is allowed under section 168(k), 1400L(b)(1), or 
     1400N(d)(1).
       ``(B) Deductions.--No deduction under this subtitle shall 
     be allowed for the portion of the expenses otherwise 
     allowable as a deduction taken into account in determining 
     the credit under this section for the taxable year which is 
     equal to the amount of the credit determined for such taxable 
     year under subsection (a) attributable to such portion. This 
     subparagraph shall not apply to expenses related to property 
     of a character subject to an allowance for depreciation the 
     basis of which is reduced under paragraph (1), or which are 
     described in section 280C(g).
       ``(C) Credit for research activities.--
       ``(i) In general.--Except as provided in clause (ii), any 
     expenses taken into account under this section for a taxable 
     year shall not be taken into account for purposes of 
     determining the credit allowable under section 41 or 45C for 
     such taxable year.
       ``(ii) Expenses included in determining base period 
     research expenses.--Any expenses for any taxable year which 
     are qualified research expenses (within the meaning of 
     section 41(b)) shall be taken into account in determining 
     base period research expenses for purposes of applying 
     section 41 to subsequent taxable years.
       ``(f) Coordination With Department of Treasury Grants.--In 
     the case of any investment with respect to which the 
     Secretary makes a grant under section 9023(e) of the Patient 
     Protection and Affordable Care Act of 2009--
       ``(1) Denial of credit.--No credit shall be determined 
     under this section with respect to such investment for the 
     taxable year in which such grant is made or any subsequent 
     taxable year.
       ``(2) Recapture of credits for progress expenditures made 
     before grant.--If a credit was determined under this section 
     with respect to such investment for any taxable year ending 
     before such grant is made--
       ``(A) the tax imposed under subtitle A on the taxpayer for 
     the taxable year in which such grant is made shall be 
     increased by so much of such credit as was allowed under 
     section 38,
       ``(B) the general business carryforwards under section 39 
     shall be adjusted so as to recapture the portion of such 
     credit which was not so allowed, and
       ``(C) the amount of such grant shall be determined without 
     regard to any reduction in the basis of any property of a 
     character subject to an allowance for depreciation by reason 
     of such credit.
       ``(3) Treatment of grants.--Any such grant shall not be 
     includible in the gross income of the taxpayer.''.
       (b) Inclusion as Part of Investment Credit.--Section 46 of 
     the Internal Revenue Code of 1986 is amended--
       (1) by adding a comma at the end of paragraph (2),
       (2) by striking the period at the end of paragraph (5) and 
     inserting ``, and'', and
       (3) by adding at the end the following new paragraph:
       ``(6) the qualifying therapeutic discovery project 
     credit.''.
       (c) Conforming Amendments.--
       (1) Section 49(a)(1)(C) of the Internal Revenue Code of 
     1986 is amended--
       (A) by striking ``and'' at the end of clause (iv),
       (B) by striking the period at the end of clause (v) and 
     inserting ``, and'', and
       (C) by adding at the end the following new clause:
       ``(vi) the basis of any property to which paragraph (1) of 
     section 48D(e) applies which is part of a qualifying 
     therapeutic discovery project under such section 48D.''.
       (2) Section 280C of such Code is amended by adding at the 
     end the following new subsection:
       ``(g) Qualifying Therapeutic Discovery Project Credit.--
       ``(1) In general.--No deduction shall be allowed for that 
     portion of the qualified investment (as defined in section 
     48D(b)) otherwise allowable as a deduction for the taxable 
     year which--
       ``(A) would be qualified research expenses (as defined in 
     section 41(b)), basic research expenses (as defined in 
     section 41(e)(2)), or qualified clinical testing expenses (as 
     defined in section 45C(b)) if the credit under section 41 or 
     section 45C were allowed with respect to such expenses for 
     such taxable year, and
       ``(B) is equal to the amount of the credit determined for 
     such taxable year under section 48D(a), reduced by--
       ``(i) the amount disallowed as a deduction by reason of 
     section 48D(e)(2)(B), and
       ``(ii) the amount of any basis reduction under section 
     48D(e)(1).
       ``(2) Similar rule where taxpayer capitalizes rather than 
     deducts expenses.--In the case of expenses described in 
     paragraph (1)(A) taken into account in determining the credit 
     under section 48D for the taxable year, if--
       ``(A) the amount of the portion of the credit determined 
     under such section with respect to such expenses, exceeds
       ``(B) the amount allowable as a deduction for such taxable 
     year for such expenses (determined without regard to 
     paragraph (1)),

     the amount chargeable to capital account for the taxable year 
     for such expenses shall be reduced by the amount of such 
     excess.
       ``(3) Controlled groups.--Paragraph (3) of subsection (b) 
     shall apply for purposes of this subsection.''.
       (d) Clerical Amendment.--The table of sections for subpart 
     E of part IV of subchapter A of chapter 1 of the Internal 
     Revenue Code of 1986 is amended by inserting after the item 
     relating to section 48C the following new item:

``Sec. 48D. Qualifying therapeutic discovery project credit.''.

       (e) Grants for Qualified Investments in Therapeutic 
     Discovery Projects in Lieu of Tax Credits.--
       (1) In general.--Upon application, the Secretary of the 
     Treasury shall, subject to the requirements of this 
     subsection, provide a grant to each person who makes a 
     qualified investment in a qualifying therapeutic discovery 
     project in the amount of 50 percent of such investment. No 
     grant shall be made under this subsection with respect to any 
     investment unless such investment is made during a taxable 
     year beginning in 2009 or 2010.
       (2) Application.--
       (A) In general.--At the stated election of the applicant, 
     an application for certification under section 48D(d)(2) of 
     the Internal Revenue Code of 1986 for a credit under such 
     section for the taxable year of the applicant which begins in 
     2009 shall be considered to be an application for a grant 
     under paragraph (1) for such taxable year.
       (B) Taxable years beginning in 2010.--An application for a 
     grant under paragraph (1) for a taxable year beginning in 
     2010 shall be submitted--
       (i) not earlier than the day after the last day of such 
     taxable year, and
       (ii) not later than the due date (including extensions) for 
     filing the return of tax for such taxable year.
       (C) Information to be submitted.--An application for a 
     grant under paragraph (1) shall include such information and 
     be in such form as the Secretary may require to state the 
     amount of the credit allowable (but for the receipt of a 
     grant under this subsection) under section 48D for the 
     taxable year for the qualified investment with respect to 
     which such application is made.
       (3) Time for payment of grant.--
       (A) In general.--The Secretary of the Treasury shall make 
     payment of the amount of any grant under paragraph (1) during 
     the 30-day period beginning on the later of--
       (i) the date of the application for such grant, or
       (ii) the date the qualified investment for which the grant 
     is being made is made.
       (B) Regulations.--In the case of investments of an ongoing 
     nature, the Secretary shall issue regulations to determine 
     the date on which a qualified investment shall be deemed to 
     have been made for purposes of this paragraph.
       (4) Qualified investment.--For purposes of this subsection, 
     the term ``qualified investment'' means a qualified 
     investment that is certified under section 48D(d) of the 
     Internal Revenue Code of 1986 for purposes of the credit 
     under such section 48D.
       (5) Application of certain rules.--
       (A) In general.--In making grants under this subsection, 
     the Secretary of the Treasury shall apply rules similar to 
     the rules of section 50 of the Internal Revenue Code of 1986. 
     In applying such rules, any increase in tax under chapter 1 
     of such Code by reason of an investment ceasing to be a 
     qualified investment shall be imposed on the person to whom 
     the grant was made.
       (B) Special rules.--
       (i) Recapture of excessive grant amounts.--If the amount of 
     a grant made under this subsection exceeds the amount 
     allowable as a grant under this subsection, such excess shall 
     be recaptured under subparagraph (A) as if the investment to 
     which such excess portion of the grant relates had ceased to 
     be a qualified investment immediately after such grant was 
     made.
       (ii) Grant information not treated as return information.--
     In no event shall the amount of a grant made under paragraph 
     (1), the identity of the person to whom such grant was made, 
     or a description of the investment with respect to which such 
     grant was made be treated as return information for purposes 
     of section 6103 of the Internal Revenue Code of 1986.
       (6) Exception for certain non-taxpayers.--The Secretary of 
     the Treasury shall not make any grant under this subsection 
     to--
       (A) any Federal, State, or local government (or any 
     political subdivision, agency, or instrumentality thereof),
       (B) any organization described in section 501(c) of the 
     Internal Revenue Code of 1986 and exempt from tax under 
     section 501(a) of such Code,
       (C) any entity referred to in paragraph (4) of section 
     54(j) of such Code, or
       (D) any partnership or other pass-thru entity any partner 
     (or other holder of an equity or profits interest) of which 
     is described in subparagraph (A), (B) or (C).

     In the case of a partnership or other pass-thru entity 
     described in subparagraph (D), partners and other holders of 
     any equity or profits interest shall provide to such 
     partnership or entity such information as the Secretary of 
     the Treasury may require to carry out the purposes of this 
     paragraph.
       (7) Secretary.--Any reference in this subsection to the 
     Secretary of the Treasury shall be treated as including the 
     Secretary's delegate.
       (8) Other terms.--Any term used in this subsection which is 
     also used in section 48D of the Internal Revenue Code of 1986 
     shall have the same meaning for purposes of this subsection 
     as when used in such section.
       (9) Denial of double benefit.--No credit shall be allowed 
     under section 46(6) of the Internal Revenue Code of 1986 by 
     reason of section

[[Page 4407]]

     48D of such Code for any investment for which a grant is 
     awarded under this subsection.
       (10) Appropriations.--There is hereby appropriated to the 
     Secretary of the Treasury such sums as may be necessary to 
     carry out this subsection.
       (11) Termination.--The Secretary of the Treasury shall not 
     make any grant to any person under this subsection unless the 
     application of such person for such grant is received before 
     January 1, 2013.
       (12) Protecting middle class families from tax increases.--
     It is the sense of the Senate that the Senate should reject 
     any procedural maneuver that would raise taxes on middle 
     class families, such as a motion to commit the pending 
     legislation to the Committee on Finance, which is designed to 
     kill legislation that provides tax cuts for American workers 
     and families, including the affordability tax credit and the 
     small business tax credit.
       (f) Effective Date.--The amendments made by subsections (a) 
     through (d) of this section shall apply to amounts paid or 
     incurred after December 31, 2008, in taxable years beginning 
     after such date.

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

               Subtitle A--Provisions Relating to Title I

     SEC. 10101. AMENDMENTS TO SUBTITLE A.

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

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

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

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

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

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

       ``(a) In General.--A group health plan (other than a self-
     insured plan) shall satisfy the requirements of section 
     105(h)(2) of the Internal Revenue Code of 1986 (relating to 
     prohibition on discrimination in favor of highly compensated 
     individuals).
       ``(b) Rules and Definitions.--For purposes of this 
     section--
       ``(1) Certain rules to apply.--Rules similar to the rules 
     contained in paragraphs (3), (4), and (8) of section 105(h) 
     of such Code shall apply.
       ``(2) Highly compensated individual.--The term `highly 
     compensated individual' has the meaning given such term by 
     section 105(h)(5) of such Code.''.
       (e) Section 2717 of the Public Health Service Act, as added 
     by section 1001(5) of this Act, is amended--
       (1) by redesignating subsections (c) and (d) as subsections 
     (d) and (e), respectively; and
       (2) by inserting after subsection (b), the following:
       ``(c) Protection of Second Amendment Gun Rights.--
       ``(1) Wellness and prevention programs.--A wellness and 
     health promotion activity implemented under subsection 
     (a)(1)(D) may not require the disclosure or collection of any 
     information relating to--
       ``(A) the presence or storage of a lawfully-possessed 
     firearm or ammunition in the residence or on the property of 
     an individual; or
       ``(B) the lawful use, possession, or storage of a firearm 
     or ammunition by an individual.
       ``(2) Limitation on data collection.--None of the 
     authorities provided to the Secretary under the Patient 
     Protection and Affordable Care Act or an amendment made by 
     that Act shall be construed to authorize or may be used for 
     the collection of any information relating to--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition;
       ``(B) the lawful use of a firearm or ammunition; or
       ``(C) the lawful storage of a firearm or ammunition.
       ``(3) Limitation on databases or data banks.--None of the 
     authorities provided to the Secretary under the Patient 
     Protection and Affordable Care Act or an amendment made by 
     that Act shall be construed to authorize or may be used to 
     maintain records of individual ownership or possession of a 
     firearm or ammunition.
       ``(4) Limitation on determination of premium rates or 
     eligibility for health insurance.--A premium rate may not be 
     increased, health insurance coverage may not be denied, and a 
     discount, rebate, or reward offered for participation in a 
     wellness program may not be reduced or withheld under any 
     health benefit plan issued pursuant to or in accordance with 
     the Patient Protection and Affordable Care Act or an 
     amendment made by that Act on the basis of, or on reliance 
     upon--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition; or
       ``(B) the lawful use or storage of a firearm or ammunition.
       ``(5) Limitation on data collection requirements for 
     individuals.--No individual shall be required to disclose any 
     information under any data collection activity authorized 
     under the Patient Protection and Affordable Care Act or an 
     amendment made by that Act relating to--
       ``(A) the lawful ownership or possession of a firearm or 
     ammunition; or
       ``(B) the lawful use, possession, or storage of a firearm 
     or ammunition.''.
       (f) Section 2718 of the Public Health Service Act, as added 
     by section 1001(5), is amended to read as follows:

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

       ``(a) Clear Accounting for Costs.--A health insurance 
     issuer offering group or individual health insurance coverage 
     (including a grandfathered health plan) shall, with respect 
     to each plan year, submit to the Secretary a report 
     concerning the ratio of the incurred loss (or incurred 
     claims) plus the loss adjustment expense (or change in 
     contract reserves) to earned premiums. Such report shall 
     include the percentage of total premium revenue, after 
     accounting for collections or receipts for risk adjustment 
     and risk corridors and payments of reinsurance, that such 
     coverage expends--
       ``(1) on reimbursement for clinical services provided to 
     enrollees under such coverage;
       ``(2) for activities that improve health care quality; and
       ``(3) on all other non-claims costs, including an 
     explanation of the nature of such costs, and excluding 
     Federal and State taxes and licensing or regulatory fees.

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

       ``(I) the amount by which the percentage described in 
     clause (i) or (ii) of subparagraph (A) exceeds the ratio 
     described in such subparagraph; and

[[Page 4408]]

       ``(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)--
       ``(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.

[[Page 4409]]

     Such professional shall agree to otherwise adhere to such 
     plan's or issuer's policies and procedures, including 
     procedures regarding referrals and obtaining prior 
     authorization and providing services pursuant to a treatment 
     plan (if any) approved by the plan or issuer.
       ``(B) Obstetrical and gynecological care.--A group health 
     plan or health insurance issuer described in paragraph (2) 
     shall treat the provision of obstetrical and gynecological 
     care, and the ordering of related obstetrical and 
     gynecological items and services, pursuant to the direct 
     access described under subparagraph (A), by a participating 
     health care professional who specializes in obstetrics or 
     gynecology as the authorization of the primary care provider.
       ``(2) Application of paragraph.--A group health plan, or 
     health insurance issuer offering group or individual health 
     insurance coverage, described in this paragraph is a group 
     health plan or coverage that--
       ``(A) provides coverage for obstetric or gynecologic care; 
     and
       ``(B) requires the designation by a participant, 
     beneficiary, or enrollee of a participating primary care 
     provider.
       ``(3) Construction.--Nothing in paragraph (1) shall be 
     construed to--
       ``(A) waive any exclusions of coverage under the terms and 
     conditions of the plan or health insurance coverage with 
     respect to coverage of obstetrical or gynecological care; or
       ``(B) preclude the group health plan or health insurance 
     issuer involved from requiring that the obstetrical or 
     gynecological provider notify the primary care health care 
     professional or the plan or issuer of treatment decisions.''.
       (i) Section 2794 of the Public Health Service Act, as added 
     by section 1003 of this Act, is amended--
       (1) in subsection (c)(1)--
       (A) in subparagraph (A), by striking ``and'' at the end;
       (B) in subparagraph (B), by striking the period and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(C) in establishing centers (consistent with subsection 
     (d)) at academic or other nonprofit institutions to collect 
     medical reimbursement information from health insurance 
     issuers, to analyze and organize such information, and to 
     make such information available to such issuers, health care 
     providers, health researchers, health care policy makers, and 
     the general public.''; and
       (2) by adding at the end the following:
       ``(d) Medical Reimbursement Data Centers.--
       ``(1) Functions.--A center established under subsection 
     (c)(1)(C) shall--
       ``(A) develop fee schedules and other database tools that 
     fairly and accurately reflect market rates for medical 
     services and the geographic differences in those rates;
       ``(B) use the best available statistical methods and data 
     processing technology to develop such fee schedules and other 
     database tools;
       ``(C) regularly update such fee schedules and other 
     database tools to reflect changes in charges for medical 
     services;
       ``(D) make health care cost information readily available 
     to the public through an Internet website that allows 
     consumers to understand the amounts that health care 
     providers in their area charge for particular medical 
     services; and
       ``(E) regularly publish information concerning the 
     statistical methodologies used by the center to analyze 
     health charge data and make such data available to 
     researchers and policy makers.
       ``(2) Conflicts of interest.--A center established under 
     subsection (c)(1)(C) shall adopt by-laws that ensures that 
     the center (and all members of the governing board of the 
     center) is independent and free from all conflicts of 
     interest. Such by-laws shall ensure that the center is not 
     controlled or influenced by, and does not have any corporate 
     relation to, any individual or entity that may make or 
     receive payments for health care services based on the 
     center's analysis of health care costs.
       ``(3) Rule of construction.--Nothing in this subsection 
     shall be construed to permit a center established under 
     subsection (c)(1)(C) to compel health insurance issuers to 
     provide data to the center.''.

     SEC. 10102. AMENDMENTS TO SUBTITLE B.

       (a) Section 1102(a)(2)(B) of this Act is amended--
       (1) in the matter preceding clause (i), by striking ``group 
     health benefits plan'' and inserting ``group benefits plan 
     providing health benefits''; and
       (2) in clause (i)(I), by inserting ``or any agency or 
     instrumentality of any of the foregoing'' before the closed 
     parenthetical.
       (b) Section 1103(a) of this Act is amended--
       (1) in paragraph (1), by inserting ``, or small business 
     in,'' after ``residents of any''; and
       (2) by striking paragraph (2) and inserting the following:
       ``(2) Connecting to affordable coverage.--An Internet 
     website established under paragraph (1) shall, to the extent 
     practicable, provide ways for residents of, and small 
     businesses in, any State to receive information on at least 
     the following coverage options:
       ``(A) Health insurance coverage offered by health insurance 
     issuers, other than coverage that provides reimbursement only 
     for the treatment or mitigation of--
       ``(i) a single disease or condition; or
       ``(ii) an unreasonably limited set of diseases or 
     conditions (as determined by the Secretary).
       ``(B) Medicaid coverage under title XIX of the Social 
     Security Act.
       ``(C) Coverage under title XXI of the Social Security Act.
       ``(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.

[[Page 4410]]

       ``(iii) The Agency for Health Care Research and Quality.
       ``(iv) The Centers for Medicare & Medicaid Services.
       ``(v) cooperative group or center of any of the entities 
     described in clauses (i) through (iv) or the Department of 
     Defense or the Department of Veterans Affairs.
       ``(vi) A qualified non-governmental research entity 
     identified in the guidelines issued by the National 
     Institutes of Health for center support grants.
       ``(vii) Any of the following if the conditions described in 
     paragraph (2) are met:

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

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

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

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

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

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

     SEC. 10104. AMENDMENTS TO SUBTITLE D.

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

     ``SEC. 1303. SPECIAL RULES.

       ``(a) State Opt-out of Abortion Coverage.--
       ``(1) In general.--A State may elect to prohibit abortion 
     coverage in qualified health plans offered through an 
     Exchange in such State if such State enacts a law to provide 
     for such prohibition.
       ``(2) Termination of opt out.--A State may repeal a law 
     described in paragraph (1) and provide for the offering of 
     such services through the Exchange.
       ``(b) Special Rules Relating to Coverage of Abortion 
     Services.--
       ``(1) Voluntary choice of coverage of abortion services.--
       ``(A) In general.--Notwithstanding any other provision of 
     this title (or any amendment made by this title)--
       ``(i) nothing in this title (or any amendment made by this 
     title), shall be construed to require a qualified health plan 
     to provide coverage of services described in subparagraph 
     (B)(i) or (B)(ii) as part of its essential health benefits 
     for any plan year; and
       ``(ii) subject to subsection (a), the issuer of a qualified 
     health plan shall determine whether or not the plan provides 
     coverage of services described in subparagraph (B)(i) or 
     (B)(ii) as part of such benefits for the plan year.
       ``(B) Abortion services.--
       ``(i) Abortions for which public funding is prohibited.--
     The services described in this clause are abortions for which 
     the expenditure of Federal funds appropriated for the 
     Department of Health and Human Services is not permitted, 
     based on the law as in effect as of the date that is 6 months 
     before the beginning of the plan year involved.
       ``(ii) Abortions for which public funding is allowed.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is permitted, based on the law 
     as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       ``(2) Prohibition on the use of federal funds.--
       ``(A) In general.--If a qualified health plan provides 
     coverage of services described in paragraph (1)(B)(i), the 
     issuer of the plan shall not use any amount attributable to 
     any of the following for purposes of paying for such 
     services:
       ``(i) The credit under section 36B of the Internal Revenue 
     Code of 1986 (and the amount (if any) of the advance payment 
     of the credit under section 1412 of the Patient Protection 
     and Affordable Care Act).
       ``(ii) Any cost-sharing reduction under section 1402 of the 
     Patient Protection and Affordable Care Act (and the amount 
     (if any) of the advance payment of the reduction under 
     section 1412 of the Patient Protection and Affordable Care 
     Act).
       ``(B) Establishment of allocation accounts.--In the case of 
     a plan to which subparagraph (A) applies, the issuer of the 
     plan shall--

[[Page 4411]]

       ``(i) collect from each enrollee in the plan (without 
     regard to the enrollee's age, sex, or family status) a 
     separate payment for each of the following:

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

       ``(ii) shall deposit all such separate payments into 
     separate allocation accounts as provided in subparagraph (C).

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

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

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

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

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

       ``(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;

[[Page 4412]]

       ``(ii) in a congressional, Government Accountability 
     Office, or other Federal report, hearing, audit, or 
     investigation; or
       ``(iii) from the news media,

     unless the action is brought by the Attorney General or the 
     person bringing the action is an original source of the 
     information.
       ``(B) For purposes of this paragraph, ``original source'' 
     means an individual who either (i) prior to a public 
     disclosure under subsection (e)(4)(a), has voluntarily 
     disclosed to the Government the information on which 
     allegations or transactions in a claim are based, or (2) who 
     has knowledge that is independent of and materially adds to 
     the publicly disclosed allegations or transactions, and who 
     has voluntarily provided the information to the Government 
     before filing an action under this section.''.
       (k) Section 1313(b) of this Act is amended--
       (1) in paragraph (3), by striking ``and'' at the end;
       (2) by redesignating paragraph (4) as paragraph (5); and
       (3) by inserting after paragraph (3) the following:
       ``(4) a survey of the cost and affordability of health care 
     insurance provided under the Exchanges for owners and 
     employees of small business concerns (as defined under 
     section 3 of the Small Business Act (15 U.S.C. 632)), 
     including data on enrollees in Exchanges and individuals 
     purchasing health insurance coverage outside of Exchanges; 
     and''.
       (l) Section 1322(b) of this Act is amended--
       (1) by redesignating paragraph (3) as paragraph (4); and
       (2) by inserting after paragraph (2), the following:
       ``(3) Repayment of loans and grants.--Not later than July 
     1, 2013, and prior to awarding loans and grants under the CO-
     OP program, the Secretary shall promulgate regulations with 
     respect to the repayment of such loans and grants in a manner 
     that is consistent with State solvency regulations and other 
     similar State laws that may apply. In promulgating such 
     regulations, the Secretary shall provide that such loans 
     shall be repaid within 5 years and such grants shall be 
     repaid within 15 years, taking into consideration any 
     appropriate State reserve requirements, solvency regulations, 
     and requisite surplus note arrangements that must be 
     constructed in a State to provide for such repayment prior to 
     awarding such loans and grants.''.
       (m) Part III of subtitle D of title I of this Act is 
     amended by striking section 1323.
       (n) Section 1324(a) of this Act is amended by striking ``, 
     a community health'' and all that follows through ``1333(b)'' 
     and inserting ``, or a multi-State qualified health plan 
     under section 1334''.
       (o) Section 1331 of this Act is amended--
       (1) in subsection (d)(3)(A)(i), by striking ``85'' and 
     inserting ``95''; and
       (2) in subsection (e)(1)(B), by inserting before the 
     semicolon the following: ``, or, in the case of an alien 
     lawfully present in the United States, whose income is not 
     greater than 133 percent of the poverty line for the size of 
     the family involved but who is not eligible for the Medicaid 
     program under title XIX of the Social Security Act by reason 
     of such alien status''.
       (p) Section 1333 of this Act is amended by striking 
     subsection (b).
       (q) Part IV of subtitle D of title I of this Act is amended 
     by adding at the end the following:

     ``SEC. 1334. MULTI-STATE PLANS.

       ``(a) Oversight by the Office of Personnel Management.--
       ``(1) In general.--The Director of the Office of Personnel 
     Management (referred to in this section as the `Director') 
     shall enter into contracts with health insurance issuers 
     (which may include a group of health insurance issuers 
     affiliated either by common ownership and control or by the 
     common use of a nationally licensed service mark), without 
     regard to section 5 of title 41, United States Code, or other 
     statutes requiring competitive bidding, to offer at least 2 
     multi-State qualified health plans through each Exchange in 
     each State. Such plans shall provide individual, or in the 
     case of small employers, group coverage.
       ``(2) Terms.--Each contract entered into under paragraph 
     (1) shall be for a uniform term of at least 1 year, but may 
     be made automatically renewable from term to term in the 
     absence of notice of termination by either party. In entering 
     into such contracts, the Director shall ensure that health 
     benefits coverage is provided in accordance with the types of 
     coverage provided for under section 2701(a)(1)(A)(i) of the 
     Public Health Service Act.
       ``(3) Non-profit entities.--In entering into contracts 
     under paragraph (1), the Director shall ensure that at least 
     one contract is entered into with a non-profit entity.
       ``(4) Administration.--The Director shall implement this 
     subsection in a manner similar to the manner in which the 
     Director implements the contracting provisions with respect 
     to carriers under the Federal employees health benefit 
     program under chapter 89 of title 5, United States Code, 
     including (through negotiating with each multi-state plan)--
       ``(A) a medical loss ratio;
       ``(B) a profit margin;
       ``(C) the premiums to be charged; and
       ``(D) such other terms and conditions of coverage as are in 
     the interests of enrollees in such plans.
       ``(5) Authority to protect consumers.--The Director may 
     prohibit the offering of any multi-State health plan that 
     does not meet the terms and conditions defined by the 
     Director with respect to the elements described in 
     subparagraphs (A) through (D) of paragraph (4).
       ``(6) Assured availability of varied coverage.--In entering 
     into contracts under this subsection, the Director shall 
     ensure that with respect to multi-State qualified health 
     plans offered in an Exchange, there is at least one such plan 
     that does not provide coverage of services described in 
     section 1303(b)(1)(B)(i).
       ``(7) Withdrawal.--Approval of a contract under this 
     subsection may be withdrawn by the Director only after notice 
     and opportunity for hearing to the issuer concerned without 
     regard to subchapter II of chapter 5 and chapter 7 of title 
     5, United States Code.
       ``(b) Eligibility.--A health insurance issuer shall be 
     eligible to enter into a contract under subsection (a)(1) if 
     such issuer--
       ``(1) agrees to offer a multi-State qualified health plan 
     that meets the requirements of subsection (c) in each 
     Exchange in each State;
       ``(2) is licensed in each State and is subject to all 
     requirements of State law not inconsistent with this section, 
     including the standards and requirements that a State imposes 
     that do not prevent the application of a requirement of part 
     A of title XXVII of the Public Health Service Act or a 
     requirement of this title;
       ``(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

[[Page 4413]]

     plans provided for under this section to the extent that such 
     requirements do not conflict with a provision of this title.
       ``(g) Continued Support for FEHBP.--
       ``(1) Maintenance of effort.--Nothing in this section shall 
     be construed to permit the Director to allocate fewer 
     financial or personnel resources to the functions of the 
     Office of Personnel Management related to the administration 
     of the Federal Employees Health Benefit Program under chapter 
     89 of title 5, United States Code.
       ``(2) Separate risk pool.--Enrollees in multi-State 
     qualified health plans under this section shall be treated as 
     a separate risk pool apart from enrollees in the Federal 
     Employees Health Benefit Program under chapter 89 of title 5, 
     United States Code.
       ``(3) Authority to establish separate entities.--The 
     Director may establish such separate units or offices within 
     the Office of Personnel Management as the Director determines 
     to be appropriate to ensure that the administration of multi-
     State qualified health plans under this section does not 
     interfere with the effective administration of the Federal 
     Employees Health Benefit Program under chapter 89 of title 5, 
     United States Code.
       ``(4) Effective oversight.--The Director may appoint such 
     additional personnel as may be necessary to enable the 
     Director to carry out activities under this section.
       ``(5) Assurance of separate program.--In carrying out this 
     section, the Director shall ensure that the program under 
     this section is separate from the Federal Employees Health 
     Benefit Program under chapter 89 of title 5, United States 
     Code. Premiums paid for coverage under a multi-State 
     qualified health plan under this section shall not be 
     considered to be Federal funds for any purposes.
       ``(6) FEHBP plans not required to participate.--Nothing in 
     this section shall require that a carrier offering coverage 
     under the Federal Employees Health Benefit Program under 
     chapter 89 of title 5, United States Code, also offer a 
     multi-State qualified health plan under this section.
       ``(h) Advisory Board.--The Director shall establish an 
     advisory board to provide recommendations on the activities 
     described in this section. A significant percentage of the 
     members of such board shall be comprised of enrollees in a 
     multi-State qualified health plan, or representatives of such 
     enrollees.
       ``(i) Authorization of Appropriations.--There is authorized 
     to be appropriated, such sums as may be necessary to carry 
     out this section.''.
       (r) Section 1341 of this Act is amended--
       (1) in the section heading, by striking ``AND SMALL GROUP 
     MARKETS'' and inserting ``MARKET'';
       (2) in subsection (b)(2)(B), by striking ``paragraph 
     (1)(A)'' and inserting ``paragraph (1)(B)''; and
       (3) in subsection (c)(1)(A), by striking ``and small group 
     markets'' and inserting ``market''.

     SEC. 10105. AMENDMENTS TO SUBTITLE E.

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

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

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

     SEC. 10106. AMENDMENTS TO SUBTITLE F.

       (a) Section 1501(a)(2) of this Act is amended to read as 
     follows:
       ``(2) Effects on the national economy and interstate 
     commerce.--The effects described in this paragraph are the 
     following:
       ``(A) The requirement regulates activity that is commercial 
     and economic in nature: economic 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

[[Page 4414]]

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

     ``The Secretary shall have the authority to review the 
     accuracy of the information provided under this subsection, 
     including the applicable large employer's share under 
     paragraph (2)(C)(iv).''.

     SEC. 10107. AMENDMENTS TO SUBTITLE G.

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

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

       ``(a) In General.--The Comptroller General of the United 
     States (referred to in this section as the `Comptroller 
     General') shall conduct a study of the incidence of denials 
     of coverage for medical services and denials of applications 
     to enroll in health insurance plans, as described in 
     subsection (b), by group health plans and health insurance 
     issuers.
       ``(b) Data.--
       ``(1) In general.--In conducting the study described in 
     subsection (a), the Comptroller General shall consider 
     samples of data concerning the following:
       ``(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

[[Page 4415]]

       (C) who does not participate in a health plan offered by 
     the offering employer.
       (2) Indexing.--In the case of any calendar year beginning 
     after 2014, the Secretary shall adjust the 8 percent under 
     paragraph (1)(A)(i) and 9.8 percent under paragraph 
     (1)(A)(ii) for the calendar year to reflect the rate of 
     premium growth between the preceding calendar year and 2013 
     over the rate of income growth for such period.
       (d) Free Choice Voucher.--
       (1) Amount.--
       (A) In general.--The amount of any free choice voucher 
     provided under subsection (a) shall be equal to the monthly 
     portion of the cost of the eligible employer-sponsored plan 
     which would have been paid by the employer if the employee 
     were covered under the plan with respect to which the 
     employer pays the largest portion of the cost of the plan. 
     Such amount shall be equal to the amount the employer would 
     pay for an employee with self-only coverage unless such 
     employee elects family coverage (in which case such amount 
     shall be the amount the employer would pay for family 
     coverage).
       (B) Determination of cost.--The cost of any health plan 
     shall be determined under the rules similar to the rules of 
     section 2204 of the Public Health Service Act, except that 
     such amount shall be adjusted for age and category of 
     enrollment in accordance with regulations established by the 
     Secretary.
       (2) Use of vouchers.--An Exchange shall credit the amount 
     of any free choice voucher provided under subsection (a) to 
     the monthly premium of any qualified health plan in the 
     Exchange in which the qualified employee is enrolled and the 
     offering employer shall pay any amounts so credited to the 
     Exchange.
       (3) Payment of excess amounts.--If the amount of the free 
     choice voucher exceeds the amount of the premium of the 
     qualified health plan in which the qualified employee is 
     enrolled for such month, such excess shall be paid to the 
     employee.
       (e) Other Definitions.--Any term used in this section which 
     is also used in section 5000A of the Internal Revenue Code of 
     1986 shall have the meaning given such term under such 
     section 5000A.
       (f) Exclusion From Income for Employee.--
       (1) In general.--Part III of subchapter B of chapter 1 of 
     the Internal Revenue Code of 1986 is amended by inserting 
     after section 139C the following new section:

     ``SEC. 139D. FREE CHOICE VOUCHERS.

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

``Sec. 139D. Free choice vouchers.''.

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

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

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

[[Page 4416]]

     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 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

[[Page 4417]]

       (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).
       ``(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

[[Page 4418]]

     State Medicaid program for a fiscal year for long-term 
     services and supports (as defined by the Secretary under 
     subsection (f))(1)) are for non-institutionally-based long-
     term services and supports described in subsection (f)(1)(B);
       (2) that submits an application and meets the conditions 
     described in subsection (c); and
       (3) that is selected by the Secretary to participate in the 
     State balancing incentive payment program established under 
     this section.
       (c) Conditions.--The conditions described in this 
     subsection are the following:
       (1) Application.--The State submits an application to the 
     Secretary that includes, in addition to such other 
     information as the Secretary shall require--
       (A) a proposed budget that details the State's plan to 
     expand and diversify medical assistance for non-
     institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) under the State Medicaid 
     program during the balancing incentive period and achieve the 
     target spending percentage applicable to the State under 
     paragraph (2), including through structural changes to how 
     the State furnishes such assistance, such as through the 
     establishment of a ``no wrong door--single entry point 
     system'', optional presumptive eligibility, case management 
     services, and the use of core standardized assessment 
     instruments, and that includes a description of the new or 
     expanded offerings of such services that the State will 
     provide and the projected costs of such services; and
       (B) in the case of a State that proposes to expand the 
     provision of home and community-based services under its 
     State Medicaid program through a State plan amendment under 
     section 1915(i) of the Social Security Act, at the option of 
     the State, an election to increase the income eligibility for 
     such services from 150 percent of the poverty line to such 
     higher percentage as the State may establish for such 
     purpose, not to exceed 300 percent of the supplemental 
     security income benefit rate established by section 
     1611(b)(1) of the Social Security Act (42 U.S.C. 1382(b)(1)).
       (2) Target spending percentages.--
       (A) In the case of a balancing incentive payment State in 
     which less than 25 percent of the total expenditures for 
     long-term services and supports under the State Medicaid 
     program for fiscal year 2009 are for home and community-based 
     services, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 25 percent 
     of the total expenditures for long-term services and supports 
     under the State Medicaid program are for home and community-
     based services.
       (B) In the case of any other balancing incentive payment 
     State, the target spending percentage for the State to 
     achieve by not later than October 1, 2015, is that 50 percent 
     of the total expenditures for long-term services and supports 
     under the State Medicaid program are for home and community-
     based services.
       (3) Maintenance of eligibility requirements.--The State 
     does not apply eligibility standards, methodologies, or 
     procedures for determining eligibility for medical assistance 
     for non-institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) under the State Medicaid 
     program that are more restrictive than the eligibility 
     standards, methodologies, or procedures in effect for such 
     purposes on December 31, 2010.
       (4) Use of additional funds.--The State agrees to use the 
     additional Federal funds paid to the State as a result of 
     this section only for purposes of providing new or expanded 
     offerings of non-institutionally-based long-term services and 
     supports described in subsection (f)(1)(B) under the State 
     Medicaid program.
       (5) Structural changes.--The State agrees to make, not 
     later than the end of the 6-month period that begins on the 
     date the State submits an application under this section, the 
     following changes:
       (A) ``No wrong door--single entry point system''.--
     Development of a statewide system to enable consumers to 
     access all long-term services and supports through an agency, 
     organization, coordinated network, or portal, in accordance 
     with such standards as the State shall establish and that 
     shall provide information regarding the availability of such 
     services, how to apply for such services, referral services 
     for services and supports otherwise available in the 
     community, and determinations of financial and functional 
     eligibility for such services and supports, or assistance 
     with assessment processes for financial and functional 
     eligibility.
       (B) Conflict-free case management services.--Conflict-free 
     case management services to develop a service plan, arrange 
     for services and supports, support the beneficiary (and, if 
     appropriate, the beneficiary's caregivers) in directing the 
     provision of services and supports for the beneficiary, and 
     conduct ongoing monitoring to assure that services and 
     supports are delivered to meet the beneficiary's needs and 
     achieve intended outcomes.
       (C) Core standardized assessment instruments.--Development 
     of core standardized assessment instruments for determining 
     eligibility for non-institutionally-based long-term services 
     and supports described in subsection (f)(1)(B), which shall 
     be used in a uniform manner throughout the State, to 
     determine a beneficiary's needs for training, support 
     services, medical care, transportation, and other services, 
     and develop an individual service plan to address such needs.
       (6) Data collection.--The State agrees to collect from 
     providers of services and through such other means as the 
     State determines appropriate the following data:
       (A) Services data.--Services data from providers of non-
     institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) on a per-beneficiary basis 
     and in accordance with such standardized coding procedures as 
     the State shall establish in consultation with the Secretary.
       (B) Quality data.--Quality data on a selected set of core 
     quality measures agreed upon by the Secretary and the State 
     that are linked to population-specific outcomes measures and 
     accessible to providers.
       (C) Outcomes measures.--Outcomes measures data on a 
     selected set of core population-specific outcomes measures 
     agreed upon by the Secretary and the State that are 
     accessible to providers and include--
       (i) measures of beneficiary and family caregiver experience 
     with providers;
       (ii) measures of beneficiary and family caregiver 
     satisfaction with services; and
       (iii) measures for achieving desired outcomes appropriate 
     to a specific beneficiary, including employment, 
     participation in community life, health stability, and 
     prevention of loss in function.
       (d) Applicable Percentage Points Increase in FMAP.--The 
     applicable percentage points increase is--
       (1) in the case of a balancing incentive payment State 
     subject to the target spending percentage described in 
     subsection (c)(2)(A), 5 percentage points; and
       (2) in the case of any other balancing incentive payment 
     State, 2 percentage points.
       (e) Eligible Medical Assistance Expenditures.--
       (1) In general.--Subject to paragraph (2), medical 
     assistance described in this subsection is medical assistance 
     for non-institutionally-based long-term services and supports 
     described in subsection (f)(1)(B) that is provided by a 
     balancing incentive payment State under its State Medicaid 
     program during the balancing incentive payment period.
       (2) Limitation on payments.--In no case may the aggregate 
     amount of payments made by the Secretary to balancing 
     incentive payment States under this section during the 
     balancing incentive period exceed $3,000,000,000.
       (f) Definitions.--In this section:
       (1) Long-term services and supports defined.--The term 
     ``long-term services and supports'' has the meaning given 
     that term by Secretary and may include any of the following 
     (as defined for purposes of State Medicaid programs):
       (A) Institutionally-based long-term services and 
     supports.--Services provided in an institution, including the 
     following:
       (i) Nursing facility services.
       (ii) Services in an intermediate care facility for the 
     mentally retarded described in subsection (a)(15) of section 
     1905 of such Act.
       (B) Non-institutionally-based long-term services and 
     supports.--Services not provided in an institution, including 
     the following:
       (i) Home and community-based services provided under 
     subsection (c), (d), or (i) of section 1915 of such Act or 
     under a waiver under section 1115 of such Act.
       (ii) Home health care services.
       (iii) Personal care services.
       (iv) Services described in subsection (a)(26) of section 
     1905 of such Act (relating to PACE program services).
       (v) Self-directed personal assistance services described in 
     section 1915(j) of such Act.
       (2) Balancing incentive period.--The term ``balancing 
     incentive period'' means the period that begins on October 1, 
     2011, and ends on September 30, 2015.
       (3) Poverty line.--The term ``poverty line'' has the 
     meaning given that term in section 2110(c)(5) of the Social 
     Security Act (42 U.S.C. 1397jj(c)(5)).
       (4) State medicaid program.--The term ``State Medicaid 
     program'' means the State program for medical assistance 
     provided under a State plan under title XIX of the Social 
     Security Act and under any waiver approved with respect to 
     such State plan.

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

       (a) Section 1311(c)(1) of this Act is amended by striking 
     ``and'' at the end of subparagraph (G), by striking the 
     period at the end of subparagraph (H) and inserting ``; 
     and'', and by adding at the end the following:
       ``(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--

[[Page 4419]]

       (A) in subparagraph (A), in the first sentence, by 
     inserting before the period the following: ``if the offering 
     of such a subsidy is cost-effective, as defined for purposes 
     of paragraph (3)(A)'';
       (B) by striking subparagraph (M); and
       (C) by redesignating subparagraph (N) as subparagraph (M).
       (4) Section 2105(c)(3)(A) of the Social Security Act (42 
     U.S.C. 1397ee(c)(3)(A)) is amended--
       (A) in the matter preceding clause (i), by striking ``to'' 
     and inserting ``to--''; and
       (B) in clause (ii), by striking the period and inserting a 
     semicolon.
       (c) Section 2105 of the Social Security Act (42 U.S.C. 
     1397ee), as amended by section 2101, is amended--
       (1) in subsection (b), in the second sentence, by striking 
     ``2013'' and inserting ``2015''; and
       (2) in subsection (d)(3)--
       (A) in subparagraph (A)--
       (i) in the first sentence, by inserting ``as a condition of 
     receiving payments under section 1903(a),'' after ``2019,'';
       (ii) in clause (i), by striking ``or'' at the end;
       (iii) by redesignating clause (ii) as clause (iii); and
       (iv) by inserting after clause (i), the following:
       ``(ii) after September 30, 2015, enrolling children 
     eligible to be targeted low-income children under the State 
     child health plan in a qualified health plan that has been 
     certified by the Secretary under subparagraph (C); or'';
       (B) in subparagraph (B), by striking ``provided coverage'' 
     and inserting ``screened for eligibility for medical 
     assistance under the State plan under title XIX or a waiver 
     of that plan and, if found eligible, enrolled in such plan or 
     a waiver. In the case of such children who, as a result of 
     such screening, are determined to not be eligible for medical 
     assistance under the State plan or a waiver under title XIX, 
     the State shall establish procedures to ensure that the 
     children are enrolled in a qualified health plan that has 
     been certified by the Secretary under subparagraph (C) and is 
     offered''; and
       (C) by adding at the end the following:
       ``(C) Certification of comparability of pediatric coverage 
     offered by qualified health plans.--With respect to each 
     State, the Secretary, not later than April 1, 2015, shall 
     review the benefits offered for children and the cost-sharing 
     imposed with respect to such benefits by qualified health 
     plans offered through an Exchange established by the State 
     under section 1311 of the Patient Protection and Affordable 
     Care Act and shall certify those plans that offer benefits 
     for children and impose cost-sharing with respect to such 
     benefits that the Secretary determines are at least 
     comparable to the benefits offered and cost-sharing 
     protections provided under the State child health plan.''.
       (d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is 
     amended--
       (A) in paragraph (15), by striking ``and'' at the end; and
       (B) by striking paragraph (16) and inserting the following:
       ``(16) for fiscal year 2013, $17,406,000,000;
       ``(17) for fiscal year 2014, $19,147,000,000; and
       ``(18) for fiscal year 2015, for purposes of making 2 semi-
     annual allotments--
       ``(A) $2,850,000,000 for the period beginning on October 1, 
     2014, and ending on March 31, 2015, and
       ``(B) $2,850,000,000 for the period beginning on April 1, 
     2015, and ending on September 30, 2015.''.
       (2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), 
     as amended by section 2102(a)(1), is amended--
       (i) in the subsection heading, by striking ``2013'' and 
     inserting ``2015'';
       (ii) in paragraph (2)--
       (I) in the paragraph heading, by striking ``2012'' and 
     inserting ``2014''; and
       (II) by adding at the end the following:
       ``(B) Fiscal years 2013 and 2014.--Subject to paragraphs 
     (4) and (6), from the amount made available under paragraphs 
     (16) and (17) of subsection (a) for fiscal years 2013 and 
     2014, respectively, the Secretary shall compute a State 
     allotment for each State (including the District of Columbia 
     and each commonwealth and territory) for each such fiscal 
     year as follows:
       ``(i) Rebasing in fiscal year 2013.--For fiscal year 2013, 
     the allotment of the State is equal to the Federal payments 
     to the State that are attributable to (and countable towards) 
     the total amount of allotments available under this section 
     to the State in fiscal year 2012 (including payments made to 
     the State under subsection (n) for fiscal year 2012 as well 
     as amounts redistributed to the State in fiscal year 2012), 
     multiplied by the allotment increase factor under paragraph 
     (5) for fiscal year 2013.
       ``(ii) Growth factor update for fiscal year 2014.--For 
     fiscal year 2014, the allotment of the State is equal to the 
     sum of--

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

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

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

       (IV) in subparagraph (D)--

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

       (iv) in paragraph (4), by striking ``2013'' and inserting 
     ``2015'';
       (v) in paragraph (6)--
       (I) in subparagraph (A), by striking ``2013'' and inserting 
     ``2015''; and
       (II) in the flush language after and below subparagraph 
     (B)(ii), by striking ``or fiscal year 2012'' and inserting 
     ``, fiscal year 2012, or fiscal year 2014''; and
       (vi) in paragraph (8)--
       (I) in the paragraph heading, by striking ``2013'' and 
     inserting ``2015''; and
       (II) by striking ``2013'' and inserting ``2015''.
       (B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is 
     amended--
       (i) in paragraph (2)--
       (I) in subparagraph (A)(ii)--
       (aa) by striking ``2012'' and inserting ``2014''; and
       (bb) by striking ``2013'' and inserting ``2015'';
       (II) in subparagraph (B)--
       (aa) by striking ``2012'' and inserting ``2014''; and
       (bb) by striking ``2013'' and inserting ``2015''; and
       (ii) in paragraph (3)(A), by striking ``or a semi-annual 
     allotment period for fiscal year 2013'' and inserting 
     ``fiscal year 2013, fiscal year 2014, or a semi-annual 
     allotment period for fiscal year 2015''.
       (C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) 
     is amended--
       (i) in the paragraph heading, by striking ``2013'' and 
     inserting ``2015''; and
       (ii) in subparagraph (A), by striking ``2013'' and 
     inserting ``2015''.
       (D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is 
     amended--
       (i) in paragraph (2)(B), by inserting ``except as provided 
     in paragraph (6),'' before ``a child''; and
       (ii) by adding at the end the following new paragraph:
       ``(6) Exceptions to exclusion of children of employees of a 
     public agency in the state.--
       ``(A) In general.--A child shall not be considered to be 
     described in paragraph (2)(B) if--
       ``(i) the public agency that employs a member of the 
     child's family to which such paragraph applies satisfies 
     subparagraph (B); or
       ``(ii) subparagraph (C) applies to such child.
       ``(B) Maintenance of effort with respect to per person 
     agency contribution for family coverage.--For purposes of 
     subparagraph (A)(i), a public agency satisfies this 
     subparagraph if the amount of annual agency expenditures made 
     on behalf of each employee enrolled in health coverage paid 
     for by the agency that includes dependent coverage for the 
     most recent State fiscal year is not less than the amount of 
     such expenditures made by the agency for the 1997 State 
     fiscal year, increased by the percentage increase in the 
     medical care expenditure category of the Consumer Price Index 
     for All-Urban Consumers (all items: U.S. City Average) for 
     such preceding fiscal year.
       ``(C) Hardship exception.--For purposes of subparagraph 
     (A)(ii), this subparagraph applies to a child if the State 
     determines, on a case-by-case basis, that the annual 
     aggregate amount of premiums and cost-sharing imposed for 
     coverage of the family of the child would exceed 5 percent of 
     such family's income for the year involved.''.
       (E) Section 2113 of such Act (42 U.S.C. 1397mm) is 
     amended--
       (i) in subsection (a)(1), by striking ``2013'' and 
     inserting ``2015''; and
       (ii) in subsection (g), by striking ``$100,000,000 for the 
     period of fiscal years 2009 through 2013'' and inserting 
     ``$140,000,000 for the period of fiscal years 2009 through 
     2015''.
       (F) Section 108 of Public Law 111-3 is amended by striking 
     ``$11,706,000,000'' and all that follows through the second 
     sentence and inserting ``$15,361,000,000 to accompany the 
     allotment made for the period beginning on October 1, 2014, 
     and ending on March 31, 2015, under section 2104(a)(18)(A) of 
     the Social Security Act (42 U.S.C. 1397dd(a)(18)(A)), to 
     remain available until expended. Such amount shall be used to 
     provide allotments to States under paragraph (3) of section 
     2104(m) of the Social Security Act (42 U.S.C. 1397dd(m)) for 
     the first 6 months of fiscal year 2015 in the same manner as 
     allotments are provided under subsection (a)(18)(A) of such 
     section 2104 and subject to the same terms and conditions as 
     apply to the allotments provided from such subsection 
     (a)(18)(A).''.

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

     SEC. 10211. DEFINITIONS.

       In this part:
       (1) Accompaniment.--The term ``accompaniment'' means 
     assisting, representing, and accompanying a woman in seeking 
     judicial relief 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

[[Page 4420]]

     organization that provides social services to residents of a 
     specific geographical area via direct service or by contract 
     with a local governmental agency.
       (4) High school.--The term ``high school'' means any public 
     or private school that operates grades 10 through 12, 
     inclusive, grades 9 through 12, inclusive or grades 7 through 
     12, inclusive.
       (5) Intervention services.--The term ``intervention 
     services'' means, with respect to domestic violence, sexual 
     violence, sexual assault, or stalking, 24-hour telephone 
     hotline services for police protection and referral to 
     shelters.
       (6) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (7) State.--The term ``State'' includes the District of 
     Columbia, any commonwealth, possession, or other territory of 
     the United States, and any Indian tribe or reservation.
       (8) Supportive social services.--The term ``supportive 
     social services'' means transitional and permanent housing, 
     vocational counseling, and individual and group counseling 
     aimed at preventing domestic violence, sexual violence, 
     sexual assault, or stalking.
       (9) Violence.--The term ``violence'' means actual violence 
     and the risk or threat of violence.

     SEC. 10212. ESTABLISHMENT OF PREGNANCY ASSISTANCE FUND.

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

     SEC. 10213. PERMISSIBLE USES OF FUND.

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

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

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

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

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

       (I) shall identify the specific performance criteria or 
     standards that shall be used to prepare the report; and
       (II) may establish the form or format of the report.

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

[[Page 4421]]

     under section 10212 to make funding available to increase 
     public awareness and education concerning any services 
     available to pregnant and parenting teens and women under 
     this part, or any other resources available to pregnant and 
     parenting women in keeping with the intent and purposes of 
     this part. The State shall be responsible for setting 
     guidelines or limits as to how much of funding may be 
     utilized for public awareness and education in any funding 
     award.

     SEC. 10214. APPROPRIATIONS.

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

                PART III--INDIAN HEALTH CARE IMPROVEMENT

     SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT.

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

              Subtitle C--Provisions Relating to Title III

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

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

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

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

     SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES.

       (a) Development.--Section 931 of the Public Health Service 
     Act, as added by section 3013(a), is amended by adding at the 
     end the following new subsection:
       ``(f) Development of Outcome Measures.--
       ``(1) In general.--The Secretary shall develop, and 
     periodically update (not less than every 3 years), provider-
     level outcome measures for hospitals and physicians, as well 
     as other providers as determined appropriate by the 
     Secretary.
       ``(2) Categories of measures.--The measures developed under 
     this subsection shall include, to the extent determined 
     appropriate by the Secretary--
       ``(A) outcome measurement for acute and chronic diseases, 
     including, to the extent feasible, the 5 most prevalent and 
     resource-intensive acute and chronic medical conditions; and
       ``(B) outcome measurement for primary and preventative 
     care, including, to the extent feasible, measurements that 
     cover provision of such care for distinct patient populations 
     (such as healthy children, chronically ill adults, or infirm 
     elderly individuals).
       ``(3) Goals.--In developing such measures, the Secretary 
     shall seek to--
       ``(A) address issues regarding risk adjustment, 
     accountability, and sample size;
       ``(B) include the full scope of services that comprise a 
     cycle of care; and
       ``(C) include multiple dimensions.
       ``(4) Timeframe.--
       ``(A) Acute and chronic diseases.--Not later than 24 months 
     after the date of enactment of this Act, the Secretary shall 
     develop not less than 10 measures described in paragraph 
     (2)(A).
       ``(B) Primary and preventive care.--Not later than 36 
     months after the date of enactment of this Act, the Secretary 
     shall develop not less than 10 measures described in 
     paragraph (2)(B).''.
       (b) Hospital-acquired Conditions.--Section 1890A of the 
     Social Security Act, as amended by section 3013(b), is 
     amended by adding at the end the following new subsection:
       ``(f) Hospital Acquired Conditions.--The Secretary shall, 
     to the extent practicable, publicly report on measures for 
     hospital-acquired conditions that are currently utilized by 
     the Centers for Medicare & Medicaid Services for the 
     adjustment of the amount of payment to hospitals based on 
     rates of hospital-acquired infections.''.
       (c) Clinical Practice Guidelines.--Section 304(b) of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (Public Law 110-275) is amended by adding at the end the 
     following new paragraph:
       ``(4) Identification.--
       ``(A) In general.--Following receipt of the report 
     submitted under paragraph (2), and not less than every 3 
     years thereafter, the Secretary shall contract with the 
     Institute to employ the results of the study performed under 
     paragraph (1) and the best methods identified by the 
     Institute for the purpose of identifying existing and new 
     clinical practice guidelines that were developed using such 
     best methods, including guidelines listed in the National 
     Guideline Clearinghouse.
       ``(B) Consultation.--In carrying out the identification 
     process under subparagraph (A), the Secretary shall allow for 
     consultation with professional societies, voluntary health 
     care organizations, and expert panels.''.

     SEC. 10304. SELECTION OF EFFICIENCY MEASURES.

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

     SEC. 10305. DATA COLLECTION; PUBLIC REPORTING.

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

[[Page 4422]]

      an increasingly broad range of patient populations, 
     providers, and geographic areas over time.''.

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

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

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

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

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

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

       Section 1899 of the Social Security Act, as added by 
     section 3022, is amended by adding at the end the following 
     new subsections:
       ``(i) Option To Use Other Payment Models.--
       ``(1) In general.--If the Secretary determines appropriate, 
     the Secretary may use any of the payment models described in 
     paragraph (2) or (3) for making payments under the program 
     rather than the payment model described in subsection (d).
       ``(2) Partial capitation model.--
       ``(A) In general.--Subject to subparagraph (B), a model 
     described in this paragraph is a partial capitation model in 
     which an ACO is at financial risk for some, but not all, of 
     the items and services covered under parts A and B, such as 
     at risk for some or all physicians' services or all items and 
     services under part B. The Secretary may limit a partial 
     capitation model to ACOs that are highly integrated systems 
     of care and to ACOs capable of bearing risk, as determined to 
     be appropriate by the Secretary.
       ``(B) No additional program expenditures.--Payments to an 
     ACO for items and services under this title for beneficiaries 
     for a year under the partial capitation model shall be 
     established in a manner that does not result in spending more 
     for such ACO for such beneficiaries than would otherwise be 
     expended for such ACO for such beneficiaries for such year if 
     the model were not implemented, as estimated by the 
     Secretary.
       ``(3) Other payment models.--
       ``(A) In general.--Subject to subparagraph (B), a model 
     described in this paragraph is any payment model that the 
     Secretary determines will improve the quality and efficiency 
     of items and services furnished under this title.
       ``(B) No additional program expenditures.--Subparagraph (B) 
     of paragraph (2) shall apply to a payment model under 
     subparagraph (A) in a similar manner as such subparagraph (B) 
     applies to the payment model under paragraph (2).
       ``(j) Involvement in Private Payer and Other Third Party 
     Arrangements.--The Secretary may give preference to ACOs who 
     are participating in similar arrangements with other payers.
       ``(k) Treatment of Physician Group Practice 
     Demonstration.--During the period beginning on the date of 
     the enactment of this section and ending on the date the 
     program is established, the Secretary may enter into an 
     agreement with an ACO under the demonstration under section 
     1866A, subject to rebasing and other modifications deemed 
     appropriate by the Secretary.''.

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

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

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

       ``(ii) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     program spending under such title XVIII; and
       ``(iii) the Secretary determines that such expansion would 
     not deny or limit the coverage or provision of benefits under 
     this title for individuals.''; and
       (3) by striking subsection (g) and inserting the following 
     new subsection:
       ``(g) Application of Pilot Program to Continuing Care 
     Hospitals.--
       ``(1) In general.--In conducting the pilot program, the 
     Secretary shall apply the provisions of the program so as to 
     separately pilot test the continuing care hospital model.
       ``(2) Special rules.--In pilot testing the continuing care 
     hospital model under paragraph (1), the following rules shall 
     apply:
       ``(A) Such model shall be tested without the limitation to 
     the conditions selected under subsection (a)(2)(B).
       ``(B) Notwithstanding subsection (a)(2)(D), an episode of 
     care shall be defined as the full period that a patient stays 
     in the continuing care hospital plus the first 30 days 
     following discharge from such hospital.
       ``(3) Continuing care hospital defined.--In this 
     subsection, the term `continuing care hospital' means an 
     entity that has demonstrated the ability to meet patient care 
     and patient safety standards and that provides under common 
     management the medical and rehabilitation services provided 
     in inpatient rehabilitation hospitals and units (as defined 
     in section 1886(d)(1)(B)(ii)), long term care hospitals (as 
     defined in section 1886(d)(1)(B)(iv)(I)), and skilled nursing 
     facilities (as defined in section 1819(a)) that are located 
     in a hospital described in section 1886(d).''.
       (b) Technical Amendments.--
       (1) Section 3023 is amended by striking ``1886C'' and 
     inserting ``1866C''.
       (2) Title XVIII of the Social Security Act is amended by 
     redesignating section 1866D, as added by section 3024, as 
     section 1866E.

     SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION 
                   PROGRAM.

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

     SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE.

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

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

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

[[Page 4423]]

     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 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.''.

[[Page 4424]]



     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--
       (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

[[Page 4425]]

       (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.
       ``(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--

[[Page 4426]]

       ``(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 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

[[Page 4427]]

       ``(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.
       ``(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--

[[Page 4428]]

       (1) the Secretary determines that such expansion is 
     expected to--
       (A) reduce spending under title XVIII of the Social 
     Security Act without reducing the quality of care; or
       (B) improve the quality of care and reduce spending;
       (2) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     program spending under such title XVIII; and
       (3) the Secretary determines that such expansion would not 
     deny or limit the coverage or provision of benefits under 
     such title XIII for Medicare beneficiaries.

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

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

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

       ``(aa) the criteria for a registry (as described in 
     subsection (k)(4)); or
       ``(bb) an alternative form and manner determined 
     appropriate by the Secretary.
       ``(ii) The eligible professional, more frequently than is 
     required to qualify for or maintain board certification 
     status--

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

       ``(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

[[Page 4429]]

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

     SEC. 10331. PUBLIC REPORTING OF PERFORMANCE INFORMATION.

       (a) In General.--
       (1) Development.--Not later than January 1, 2011, the 
     Secretary shall develop a Physician Compare Internet website 
     with information on physicians enrolled in the Medicare 
     program under section 1866(j) of the Social Security Act (42 
     U.S.C. 1395cc(j)) and other eligible professionals who 
     participate in the Physician Quality Reporting Initiative 
     under section 1848 of such Act (42 U.S.C. 1395w-4).
       (2) Plan.--Not later than January 1, 2013, and with respect 
     to reporting periods that begin no earlier than January 1, 
     2012, the Secretary shall also implement a plan for making 
     publicly available through Physician Compare, consistent with 
     subsection (c), information on physician performance that 
     provides comparable information for the public on quality and 
     patient experience measures with respect to physicians 
     enrolled in the Medicare program under such section 1866(j). 
     To the extent scientifically sound measures that are 
     developed consistent with the requirements of this section 
     are available, such information, to the extent practicable, 
     shall include--
       (A) measures collected under the Physician Quality 
     Reporting Initiative;
       (B) an assessment of patient health outcomes and the 
     functional status of patients;
       (C) an assessment of the continuity and coordination of 
     care and care transitions, including episodes of care and 
     risk-adjusted resource use;
       (D) an assessment of efficiency;
       (E) an assessment of patient experience and patient, 
     caregiver, and family engagement;
       (F) an assessment of the safety, effectiveness, and 
     timeliness of care; and
       (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).

[[Page 4430]]

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

     SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

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

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

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

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

     SEC. 10334. MINORITY HEALTH.

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

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

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

[[Page 4431]]

     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.--
       (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.

[[Page 4432]]

       (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.--
       ``(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:

[[Page 4433]]

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

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

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

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

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

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

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

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

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

       ``(iv) a description of the protocols the entity will 
     follow to comply with Food and Drug Administration standards 
     and regulatory requirements at all stages of development, 
     manufacturing, review, approval, and safety surveillance of a 
     medical product; and
       ``(C) provide such additional information as the Director 
     of NIH may require.
       ``(3) Awards.--
       ``(A) The cures acceleration partnership awards.--
       ``(i) Initial award amount.--Each award under this 
     subparagraph shall be not more than $15,000,000 per project 
     for the first fiscal year for which the project is funded, 
     which shall be payable in one payment.
       ``(ii) Funding in subsequent fiscal years.--An eligible 
     entity receiving an award under clause (i) may apply for 
     additional funding for such project by submitting to the 
     Director of NIH the information required under subparagraphs 
     (B) and (C) of paragraph (2). The Director may fund a project 
     of such eligible entity in an amount not to exceed 
     $15,000,000 for a fiscal year subsequent to the initial award 
     under clause (i).
       ``(iii) Matching funds.--As a condition for receiving an 
     award under this subsection, an eligible entity shall 
     contribute to the project non-Federal funds in the amount of 
     $1 for every $3 awarded under clauses (i) and (ii), except 
     that the Director of NIH may waive or modify such matching 
     requirement in any case where the Director determines that 
     the goals and objectives of this section cannot adequately be 
     carried out unless such requirement is waived.
       ``(B) The cures acceleration grant awards.--
       ``(i) Initial award amount.--Each award under this 
     subparagraph shall be not more than $15,000,000 per project 
     for the first fiscal year for which the project is funded, 
     which shall be payable in one payment.
       ``(ii) Funding in subsequent fiscal years.--An eligible 
     entity receiving an award under clause (i) may apply for 
     additional funding for such project by submitting to the 
     Board the information required under subparagraphs (B) and 
     (C) of paragraph (2). The Director of NIH may fund a project 
     of such eligible entity in an amount not to exceed 
     $15,000,000 for a fiscal year subsequent to the initial award 
     under clause (i).
       ``(C) The cures acceleration flexible research awards.--If 
     the Director of NIH determines that the goals and objectives 
     of this section cannot adequately be carried out through a 
     contract, grant, or cooperative agreement, the Director of 
     NIH shall have flexible research authority to use other 
     transactions to fund projects in accordance with the terms 
     and conditions of this section. Awards made under such 
     flexible research authority for a fiscal year shall not 
     exceed 20 percent of the total funds appropriated under 
     subsection (g)(1) for such fiscal year.
       ``(4) Suspension of awards for defaults, noncompliance with 
     provisions and plans, and diversion of funds; repayment of 
     funds.--The Director of NIH may suspend the award to any 
     entity upon noncompliance by such entity with provisions and 
     plans under this section or diversion of funds.
       ``(5) Audits.--The Director of NIH may enter into 
     agreements with other entities to conduct periodic audits of 
     the projects funded by grants or contracts awarded under this 
     subsection.
       ``(6) Closeout procedures.--At the end of a grant or 
     contract period, a recipient shall follow the closeout 
     procedures under section 74.71 of title 45, Code of Federal 
     Regulations (or any successor regulation).
       ``(7) Review.--A determination by the Director of NIH as to 
     whether a drug, device, or biological product is a high need 
     cure (for purposes of subsection (a)(3)) shall not be subject 
     to judicial review.
       ``(f) Competitive Basis of Awards.--Any grant, cooperative 
     agreement, or contract awarded under this section shall be 
     awarded on a competitive basis.
       ``(g) Authorization of Appropriations.--
       ``(1) In general.--For purposes of carrying out this 
     section, there are authorized to be appropriated $500,000,000 
     for fiscal year 2010, and

[[Page 4434]]

     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 
     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,

[[Page 4435]]

     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 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--

[[Page 4436]]

       ``(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
       ``(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.

[[Page 4437]]

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

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

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a national diabetes prevention program 
     (referred to in this section as the `program') targeted at 
     adults at high risk for diabetes in order to eliminate the 
     preventable burden of diabetes.
       ``(b) Program Activities.--The program described in 
     subsection (a) shall include--
       ``(1) a grant program for community-based diabetes 
     prevention program model sites;
       ``(2) a program within the Centers for Disease Control and 
     Prevention to determine eligibility of entities to deliver 
     community-based diabetes prevention services;
       ``(3) a training and outreach program for lifestyle 
     intervention instructors; and
       ``(4) evaluation, monitoring and technical assistance, and 
     applied research carried out by the Centers for Disease 
     Control and Prevention.
       ``(c) Eligible Entities.--To be eligible for a grant under 
     subsection (b)(1), an entity shall be a State or local health 
     department, a tribal organization, a national network of 
     community-based non-profits focused on health and wellbeing, 
     an academic institution, or other entity, as the Secretary 
     determines.
       ``(d) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there are authorized to be 
     appropriated such sums as may be necessary for each of fiscal 
     years 2010 through 2014.''.
       (h) The provisions of, and amendment made by, section 
     5501(c) of this Act are repealed.
       (i)(1) The provisions of, and amendments made by, section 
     5502 of this Act are repealed.
       (2)(A) Section 1861(aa)(3)(A) of the Social Security Act 
     (42 U.S.C. 1395w(aa)(3)(A)) is amended to read as follows:
       ``(A) services of the type described in subparagraphs (A) 
     through (C) of paragraph (1) and preventive services (as 
     defined in section 1861(ddd)(3)); and''.
       (B) The amendment made by subparagraph (A) shall apply to 
     services furnished on or after January 1, 2011.
       (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

[[Page 4438]]

     proper appeal pending as of the date of the enactment of this 
     Act on the issue of payment for indirect costs of medical 
     education under section 1886(d)(5)(B) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate 
     medical education costs under section 1886(h) of such Act (42 
     U.S.C. 1395ww(h)).''.
       (k) Subtitle G of title V of this Act is amended by adding 
     at the end the following:

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

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

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

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

           ``Subpart II--Training in Underserved Communities

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

       ``(a) In General.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall establish a grant program for the 
     purposes of assisting eligible entities in recruiting 
     students most likely to practice medicine in underserved 
     rural communities, providing rural-focused training and 
     experience, and increasing the number of recent allopathic 
     and osteopathic medical school graduates who practice in 
     underserved rural communities.
       ``(b) Eligible Entities.--In order to be eligible to 
     receive a grant under this section, an entity shall--
       ``(1) be a school of allopathic or osteopathic medicine 
     accredited by a nationally recognized accrediting agency or 
     association approved by the Secretary for this purpose, or 
     any combination or consortium of such schools; and
       ``(2) submit an application to the Secretary that includes 
     a certification that such entity will use amounts provided to 
     the institution as described in subsection (d)(1).
       ``(c) Priority.--In awarding grant funds under this 
     section, the Secretary shall give priority to eligible 
     entities that--
       ``(1) demonstrate a record of successfully training 
     students, as determined by the Secretary, who practice 
     medicine in underserved rural communities;
       ``(2) demonstrate that an existing academic program of the 
     eligible entity produces a high percentage, as determined by 
     the Secretary, of graduates from such program who practice 
     medicine in underserved rural communities;
       ``(3) demonstrate rural community institutional 
     partnerships, through such mechanisms as matching or 
     contributory funding, documented in-kind services for 
     implementation, or existence of training partners with 
     interprofessional expertise in community health center 
     training locations or other similar facilities; or
       ``(4) submit, as part of the application of the entity 
     under subsection (b), a plan for the long-term tracking of 
     where the graduates of such entity practice medicine.
       ``(d) Use of Funds.--
       ``(1) Establishment.--An eligible entity receiving a grant 
     under this section shall use the funds made available under 
     such grant to establish, improve, or expand a rural-focused 
     training program (referred to in this section as the 
     `Program') meeting the requirements described in this 
     subsection and to carry out such program.
       ``(2) Structure of program.--An eligible entity shall--
       ``(A) enroll no fewer than 10 students per class year into 
     the Program; and
       ``(B) develop criteria for admission to the Program that 
     gives priority to students--
       ``(i) who have originated from or lived for a period of 2 
     or more years in an underserved rural community; and
       ``(ii) who express a commitment to practice medicine in an 
     underserved rural community.
       ``(3) Curricula.--The Program shall require students to 
     enroll in didactic coursework and clinical experience 
     particularly applicable to medical practice in underserved 
     rural communities, including--
       ``(A) clinical rotations in underserved rural communities, 
     and in applicable specialties, or other coursework or 
     clinical experience deemed appropriate by the Secretary; and
       ``(B) in addition to core school curricula, additional 
     coursework or training experiences focused on medical issues 
     prevalent in underserved rural communities.
       ``(4) Residency placement assistance.--Where available, the 
     Program shall assist all students of the Program in obtaining 
     clinical training experiences in locations with postgraduate 
     programs offering residency training opportunities in 
     underserved rural communities, or in local residency training 
     programs that support and train physicians to practice in 
     underserved rural communities.
       ``(5) Program student cohort support.--The Program shall 
     provide and require all students of the Program to 
     participate in group activities designed to further develop, 
     maintain, and reinforce the original commitment of such 
     students to practice in an underserved rural community.
       ``(e) Annual Reporting.--An eligible entity receiving a 
     grant under this section shall submit an annual report to the 
     Secretary on the success of the Program, based on criteria 
     the Secretary determines appropriate, including the residency 
     program selection of graduating students who participated in 
     the Program.
       ``(f) Regulations.--Not later than 60 days after the date 
     of enactment of this section, the Secretary shall by 
     regulation define `underserved rural community' for purposes 
     of this section.
       ``(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--

[[Page 4439]]

       ``(i) double the period of obligated service that would 
     otherwise be required; or
       ``(ii) in the case of contracts entered into under section 
     338B, accept a minimum service obligation of 2 years with an 
     award amount equal to 50 percent of the amount that would 
     otherwise be payable for full-time service; and''; and
       (C) in paragraph (3), by striking ``In evaluating a 
     demonstration project described in paragraph (1)'' and 
     inserting ``In evaluating waivers issued under paragraph 
     (1)''.
       (2) Subsection (j) of section 331 of the Public Health 
     Service Act (42 U.S.C. 254d) is amended by adding at the end 
     the following:
       ``(5) The terms `full time' and `full-time' mean a minimum 
     of 40 hours per week in a clinical practice, for a minimum of 
     45 weeks per year.
       ``(6) The terms `half time' and `half-time' mean a minimum 
     of 20 hours per week (not to exceed 39 hours per week) in a 
     clinical practice, for a minimum of 45 weeks per year.''.
       (3) Section 337(b)(1) of the Public Health Service Act (42 
     U.S.C. 254j(b)(1)) is amended by striking ``Members may not 
     be reappointed to the Council.''.
       (4) Section 338B(g)(2)(A) of the Public Health Service Act 
     (42 U.S.C. 254l-1(g)(2)(A)) is amended by striking 
     ``$35,000'' and inserting ``$50,000, plus, beginning with 
     fiscal year 2012, an amount determined by the Secretary on an 
     annual basis to reflect inflation,''.
       (5) Subsection (a) of section 338C of the Public Health 
     Service Act (42 U.S.C. 254m), as amended by section 5508, is 
     amended--
       (A) by striking the second sentence and inserting the 
     following: ``The Secretary may treat teaching as clinical 
     practice for up to 20 percent of such period of obligated 
     service.''; and
       (B) by adding at the end the following: ``Notwithstanding 
     the preceding sentence, with respect to a member of the Corps 
     participating in the teaching health centers graduate medical 
     education program under section 340H, for the purpose of 
     calculating time spent in full-time clinical practice under 
     this section, up to 50 percent of time spent teaching by such 
     member may be counted toward his or her service 
     obligation.''.

     SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE.

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

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

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

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

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

              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

[[Page 4440]]

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

     SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT.

       (a) Fraud Sentencing Guidelines.--
       (1) Definition.--In this subsection, the term ``Federal 
     health care offense'' has the meaning given that term in 
     section 24 of title 18, United States Code, as amended by 
     this Act.
       (2) Review and amendments.--Pursuant to the authority under 
     section 994 of title 28, United States Code, and in 
     accordance with this subsection, the United States Sentencing 
     Commission shall--
       (A) review the Federal Sentencing Guidelines and policy 
     statements applicable to persons convicted of Federal health 
     care offenses;
       (B) amend the Federal Sentencing Guidelines and policy 
     statements applicable to persons convicted of Federal health 
     care offenses involving Government health care programs to 
     provide that the aggregate dollar amount of fraudulent bills 
     submitted to the Government health care program shall 
     constitute prima facie evidence of the amount of the intended 
     loss by the defendant; and
       (C) amend the Federal Sentencing Guidelines to provide--
       (i) a 2-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $1,000,000 and less than $7,000,000;
       (ii) a 3-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $7,000,000 and less than $20,000,000;
       (iii) a 4-level increase in the offense level for any 
     defendant convicted of a Federal health care offense relating 
     to a Government health care program which involves a loss of 
     not less than $20,000,000; and
       (iv) if appropriate, otherwise amend the Federal Sentencing 
     Guidelines and policy statements applicable to persons 
     convicted of Federal health care offenses involving 
     Government health care programs.
       (3) Requirements.--In carrying this subsection, the United 
     States Sentencing Commission shall--
       (A) ensure that the Federal Sentencing Guidelines and 
     policy statements--
       (i) reflect the serious harms associated with health care 
     fraud and the need for aggressive and appropriate law 
     enforcement action to prevent such fraud; and
       (ii) provide increased penalties for persons convicted of 
     health care fraud offenses in appropriate circumstances;
       (B) consult with individuals or groups representing health 
     care fraud victims, law enforcement officials, the health 
     care industry, and the Federal judiciary as part of the 
     review described in paragraph (2);
       (C) ensure reasonable consistency with other relevant 
     directives and with other guidelines under the Federal 
     Sentencing Guidelines;
       (D) account for any aggravating or mitigating circumstances 
     that might justify exceptions, including circumstances for 
     which the Federal Sentencing Guidelines, as in effect on the 
     date of enactment of this Act, provide sentencing 
     enhancements;
       (E) make any necessary conforming changes to the Federal 
     Sentencing Guidelines; and
       (F) ensure that the Federal Sentencing Guidelines 
     adequately meet the purposes of sentencing.
       (b) Intent Requirement for Health Care Fraud.--Section 1347 
     of title 18, United States Code, is amended--
       (1) by inserting ``(a)'' before ``Whoever knowingly''; and
       (2) by adding at the end the following:
       ``(b) With respect to violations of this section, a person 
     need not have actual knowledge of this section or specific 
     intent to commit a violation of this section.''.
       (c) Health Care Fraud Offense.--Section 24(a) of title 18, 
     United States Code, is amended--
       (1) in paragraph (1), by striking the semicolon and 
     inserting ``or section 1128B of the Social Security Act (42 
     U.S.C. 1320a-7b); or''; and
       (2) in paragraph (2)--
       (A) by inserting ``1349,'' after ``1343,''; and
       (B) by inserting ``section 301 of the Federal Food, Drug, 
     and Cosmetic Act (21 U.S.C. 331), or section 501 of the 
     Employee Retirement Income Security Act of 1974 (29 U.S.C. 
     1131),'' after ``title,''.
       (d) Subpoena Authority Relating to Health Care.--
       (1) Subpoenas under the health insurance portability and 
     accountability act of 1996.--Section 1510(b) of title 18, 
     United States Code, is amended--
       (A) in paragraph (1), by striking ``to the grand jury''; 
     and
       (B) in paragraph (2)--
       (i) in subparagraph (A), by striking ``grand jury 
     subpoena'' and inserting ``subpoena for records''; and
       (ii) in the matter following subparagraph (B), by striking 
     ``to the grand jury''.
       (2) Subpoenas under the civil rights of institutionalized 
     persons act.--The Civil Rights of Institutionalized Persons 
     Act (42 U.S.C. 1997 et seq.) is amended by inserting after 
     section 3 the following:

     ``SEC. 3A. SUBPOENA AUTHORITY.

       ``(a) Authority.--The Attorney General, or at the direction 
     of the Attorney General, any officer or employee of the 
     Department of Justice may require by subpoena access to any 
     institution that is the subject of an investigation under 
     this Act and to any document, record, material, file, report, 
     memorandum, policy, procedure, investigation, video or audio 
     recording, or quality assurance report relating to any 
     institution that is the subject of an investigation under 
     this Act to determine whether there are conditions which 
     deprive persons residing in or confined to the institution of 
     any rights, privileges, or immunities secured or protected by 
     the Constitution or laws of the United States.
       ``(b) Issuance and Enforcement of Subpoenas.--
       ``(1) Issuance.--Subpoenas issued under this section--
       ``(A) shall bear the signature of the Attorney General or 
     any officer or employee of the Department of Justice as 
     designated by the Attorney General; and
       ``(B) shall be served by any person or class of persons 
     designated by the Attorney General or a designated officer or 
     employee for that purpose.
       ``(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;

[[Page 4441]]

       ``(E) improves access to liability insurance;
       ``(F) fully informs patients about the differences in the 
     alternative and current tort litigation;
       ``(G) provides patients the ability to opt out of or 
     voluntarily withdraw from participating in the alternative at 
     any time and to pursue other options, including litigation, 
     outside the alternative;
       ``(H) would not conflict with State law at the time of the 
     application in a way that would prohibit the adoption of an 
     alternative to current tort litigation; and
       ``(I) would not limit or curtail a patient's existing legal 
     rights, ability to file a claim in or access a State's legal 
     system, or otherwise abrogate a patient's ability to file a 
     medical malpractice claim.
       ``(3) Sources of compensation.--Each State desiring a grant 
     under subsection (a) shall identify the sources from and 
     methods by which compensation would be paid for claims 
     resolved under the proposed alternative to current tort 
     litigation, which may include public or private funding 
     sources, or a combination of such sources. Funding methods 
     shall to the extent practicable provide financial incentives 
     for activities that improve patient safety.
       ``(4) Scope.--
       ``(A) In general.--Each State desiring a grant under 
     subsection (a) shall establish a scope of jurisdiction (such 
     as Statewide, designated geographic region, a designated area 
     of health care practice, or a designated group of health care 
     providers or health care organizations) for the proposed 
     alternative to current tort litigation that is sufficient to 
     evaluate the effects of the alternative. No scope of 
     jurisdiction shall be established under this paragraph that 
     is based on a health care payer or patient population.
       ``(B) Notification of patients.--A State shall demonstrate 
     how patients would be notified that they are receiving health 
     care services that fall within such scope, and the process by 
     which they may opt out of or voluntarily withdraw from 
     participating in the alternative. The decision of the patient 
     whether to participate or continue participating in the 
     alternative process shall be made at any time and shall not 
     be limited in any way.
       ``(5) Preference in awarding demonstration grants.--In 
     awarding grants under subsection (a), the Secretary shall 
     give preference to States--
       ``(A) that have developed the proposed alternative through 
     substantive consultation with relevant stakeholders, 
     including patient advocates, health care providers and health 
     care organizations, attorneys with expertise in representing 
     patients and health care providers, medical malpractice 
     insurers, and patient safety experts;
       ``(B) that make proposals that are likely to enhance 
     patient safety by detecting, analyzing, and helping to reduce 
     medical errors and adverse events; and
       ``(C) that make proposals that are likely to improve access 
     to liability insurance.
       ``(d) Application.--
       ``(1) In general.--Each State desiring a grant under 
     subsection (a) shall submit to the Secretary an application, 
     at such time, in such manner, and containing such information 
     as the Secretary may require.
       ``(2) Review panel.--
       ``(A) In general.--In reviewing applications under 
     paragraph (1), the Secretary shall consult with a review 
     panel composed of relevant experts appointed by the 
     Comptroller General.
       ``(B) Composition.--
       ``(i) Nominations.--The Comptroller General shall solicit 
     nominations from the public for individuals to serve on the 
     review panel.
       ``(ii) Appointment.--The Comptroller General shall appoint, 
     at least 9 but not more than 13, highly qualified and 
     knowledgeable individuals to serve on the review panel and 
     shall ensure that the following entities receive fair 
     representation on such panel:

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

       ``(C) Chairperson.--The Comptroller General, or an 
     individual within the Government Accountability Office 
     designated by the Comptroller General, shall be the 
     chairperson of the review panel.
       ``(D) Availability of information.--The Comptroller General 
     shall make available to the review panel such information, 
     personnel, and administrative services and assistance as the 
     review panel may reasonably require to carry out its duties.
       ``(E) Information from agencies.--The review panel may 
     request directly from any department or agency of the United 
     States any information that such panel considers necessary to 
     carry out its duties. To the extent consistent with 
     applicable laws and regulations, the head of such department 
     or agency shall furnish the requested information to the 
     review panel.
       ``(e) Reports.--
       ``(1) By state.--Each State receiving a grant under 
     subsection (a) shall submit to the Secretary an annual report 
     evaluating the effectiveness of activities funded with grants 
     awarded under such subsection. Such report shall, at a 
     minimum, include the impact of the activities funded on 
     patient safety and on the availability and price of medical 
     liability insurance.
       ``(2) By secretary.--The Secretary shall submit to Congress 
     an annual compendium of the reports submitted under paragraph 
     (1) and an analysis of the activities funded under subsection 
     (a) that examines any differences that result from such 
     activities in terms of the quality of care, number and nature 
     of medical errors, medical resources used, length of time for 
     dispute resolution, and the availability and price of 
     liability insurance.
       ``(f) Technical Assistance.--
       ``(1) In general.--The Secretary shall provide technical 
     assistance to the States applying for or awarded grants under 
     subsection (a).
       ``(2) Requirements.--Technical assistance under paragraph 
     (1) shall include--
       ``(A) guidance on non-economic damages, including the 
     consideration of individual facts and circumstances in 
     determining appropriate payment, guidance on identifying 
     avoidable injuries, and guidance on disclosure to patients of 
     health care errors and adverse events; and
       ``(B) the development, in consultation with States, of 
     common definitions, formats, and data collection 
     infrastructure for States receiving grants under this section 
     to use in reporting to facilitate aggregation and analysis of 
     data both within and between States.
       ``(3) Use of common definitions, formats, and data 
     collection infrastructure.--States not receiving grants under 
     this section may also use the common definitions, formats, 
     and data collection infrastructure developed under paragraph 
     (2)(B).
       ``(g) Evaluation.--
       ``(1) In general.--The Secretary, in consultation with the 
     review panel established under subsection (d)(2), shall enter 
     into a contract with an appropriate research organization to 
     conduct an overall evaluation of the effectiveness of grants 
     awarded under subsection (a) and to annually prepare and 
     submit a report to Congress. Such an evaluation shall begin 
     not later than 18 months following the date of implementation 
     of the first program funded by a grant under subsection (a).
       ``(2) Contents.--The evaluation under paragraph (1) shall 
     include--
       ``(A) an analysis of the effects of the grants awarded 
     under subsection (a) with regard to the measures described in 
     paragraph (3);
       ``(B) for each State, an analysis of the extent to which 
     the alternative developed under subsection (c)(1) is 
     effective in meeting the elements described in subsection 
     (c)(2);
       ``(C) a comparison among the States receiving grants under 
     subsection (a) of the effectiveness 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

[[Page 4442]]

     recommendations of each respective Commission based on 
     independent reviews conducted under paragraphs (1) and (2), 
     including an analysis of the impact of the alternatives 
     reviewed on the efficiency and effectiveness of the 
     respective programs.
       ``(i) Option To Provide for Initial Planning Grants.--Of 
     the funds appropriated pursuant to subsection (k), the 
     Secretary may use a portion not to exceed $500,000 per State 
     to provide planning grants to such States for the development 
     of demonstration project applications meeting the criteria 
     described in subsection (c). In selecting States to receive 
     such planning grants, the Secretary shall give preference to 
     those States in which State law at the time of the 
     application would not prohibit the adoption of an alternative 
     to current tort litigation.
       ``(j) Definitions.--In this section:
       ``(1) Health care services.--The term `health care 
     services' means any services provided by a health care 
     provider, or by any individual working under the supervision 
     of a health care provider, that relate to--
       ``(A) the diagnosis, prevention, or treatment of any human 
     disease or impairment; or
       ``(B) the assessment of the health of human beings.
       ``(2) Health care organization.--The term `health care 
     organization' means any individual or entity which is 
     obligated to provide, pay for, or administer health benefits 
     under any health plan.
       ``(3) Health care provider.--The term `health care 
     provider' means any individual or entity--
       ``(A) licensed, registered, or certified under Federal or 
     State laws or regulations to provide health care services; or
       ``(B) required to be so licensed, registered, or certified 
     but that is exempted by other statute or regulation.
       ``(k) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section, 
     $50,000,000 for the 5-fiscal year period beginning with 
     fiscal year 2011.
       ``(l) Current State Efforts To Establish Alternative To 
     Tort Litigation.--Nothing in this section shall be construed 
     to limit any prior, current, or future efforts of any State 
     to establish any alternative to tort litigation.
       ``(m) Rule of Construction.--Nothing in this section shall 
     be construed as limiting states' authority over or 
     responsibility for their state justice systems.''.

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

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

     SEC. 10609. LABELING CHANGES.

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

             Subtitle G--Provisions Relating to Title VIII

     SEC. 10801. PROVISIONS RELATING TO TITLE VIII.

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

              Subtitle H--Provisions Relating to Title IX

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

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

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

       (a) In General.--Subsection (i) of section 125 of the 
     Internal Revenue Code of 1986, as added by section 9005 of 
     this Act, is amended to read as follows:
       ``(i) Limitation on Health Flexible Spending 
     Arrangements.--
       ``(1) In general.--For purposes of this section, if a 
     benefit is provided under a cafeteria plan through employer 
     contributions to a health flexible spending arrangement, such 
     benefit shall not be treated as a qualified benefit unless 
     the cafeteria plan provides that an employee may not elect 
     for any taxable year to have salary reduction contributions 
     in excess of $2,500 made to such arrangement.
       ``(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

[[Page 4443]]

     entities that are taken into account during such preceding 
     calendar year.
       ``(2) Amounts taken into account.--For purposes of 
     paragraph (1), the net premiums written with respect to 
     health insurance for any United States health risk that are 
     taken into account during any calendar year with respect to 
     any covered entity shall be determined in accordance with the 
     following table:


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

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


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


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

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

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

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

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

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

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

     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 4444]]

                   ``Chapter 49--Cosmetic Services''.

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

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

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

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

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

``Sec. 36C. Adoption expenses.''.
       (c) Application and Extension of EGTRRA Sunset.--
     Notwithstanding section 901 of the Economic Growth and Tax 
     Relief Reconciliation Act of 2001, such section shall apply 
     to the amendments made by this section and the amendments 
     made by section 202 of such Act by substituting ``December 
     31, 2011'' for ``December 31, 2010'' in subsection (a)(1) 
     thereof.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2009.

       Amend the title so as to read: ``An Act entitled The 
     Patient Protection and Affordable Care Act.''.


                            Motion to Concur

  The SPEAKER pro tempore. The Clerk will designate the motion.
  The text of the motion is as follows:

       Mr. Spratt moves that the House concur in the Senate 
     amendments to H.R. 3590.

  The SPEAKER pro tempore. Pursuant to section 2 of House Resolution 
1203, the previous question is ordered on the motion.
  The question is on the motion.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. BOEHNER. Mr. Speaker, on that I request a recorded vote and 
request that the Speaker exercise your discretion to conduct this vote 
by a rollcall under clause 2 of House rule XX.
  The SPEAKER pro tempore. A recorded vote is requested. Those favoring 
a recorded vote will rise. A sufficient number having risen, a recorded 
vote is ordered. Members will record their vote by electronic device.
  The vote was taken by electronic device, and there were--ayes 219, 
noes 212, not voting 0, as follows:

                             [Roll No. 165]

                               AYES--219

     Ackerman
     Andrews
     Baca
     Baird
     Baldwin
     Bean
     Becerra
     Berkley
     Berman
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boswell
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (CA)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro

[[Page 4445]]


     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Klein (FL)
     Kosmas
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Miller, George
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Nadler (NY)
     Napolitano
     Neal (MA)
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Pelosi
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Sires
     Slaughter
     Smith (WA)
     Snyder
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                               NOES--212

     Aderholt
     Adler (NJ)
     Akin
     Alexander
     Altmire
     Arcuri
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Barrow
     Bartlett
     Barton (TX)
     Berry
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boucher
     Boustany
     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Carter
     Cassidy
     Castle
     Chaffetz
     Chandler
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Crenshaw
     Culberson
     Davis (AL)
     Davis (KY)
     Davis (TN)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Edwards (TX)
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Herseth Sandlin
     Hoekstra
     Holden
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kissell
     Kline (MN)
     Kratovil
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     Lipinski
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Lynch
     Mack
     Manzullo
     Marchant
     Marshall
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McIntyre
     McKeon
     McMahon
     McMorris Rodgers
     Melancon
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Minnick
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Nye
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Ross
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuler
     Shuster
     Simpson
     Skelton
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Space
     Stearns
     Sullivan
     Tanner
     Taylor
     Teague
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                              {time}  2249

  So the motion to concur was agreed to.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.
  Mr. HOYER. Mr. Speaker, pursuant to House Resolution 1203, I call up 
the bill (H.R. 4872) to provide for reconciliation pursuant to section 
202 of the concurrent resolution on the budget for fiscal year 2010, 
and ask for its immediate consideration.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore. Pursuant to section 3 of House Resolution 
1203, the amendment in the nature of a substitute printed in part A of 
House Report 111-448, modified by the amendment printed in part B of 
the report is adopted and the bill, as amended, is considered read.
  The text of the bill, as amended, is as follows:

                               H.R. 4872

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Health 
     Care and Education Reconciliation Act of 2010''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

          TITLE I--COVERAGE, MEDICARE, MEDICAID, AND REVENUES

                          Subtitle A--Coverage

Sec. 1001. Affordability.
Sec. 1002. Individual responsibility.
Sec. 1003. Employer responsibility.
Sec. 1004. Income definitions.
Sec. 1005. Implementation funding.

                          Subtitle B--Medicare

Sec. 1101. Closing the medicare prescription drug ``donut hole''.
Sec. 1102. Medicare Advantage payments.
Sec. 1103. Savings from limits on MA plan administrative costs.
Sec. 1104. Disproportionate share hospital (DSH) payments.
Sec. 1105. Market basket updates.
Sec. 1106. Physician ownership-referral.
Sec. 1107. Payment for imaging services.

                          Subtitle C--Medicaid

Sec. 1201. Federal funding for States.
Sec. 1202. Payments to primary care physicians.
Sec. 1203. Disproportionate share hospital payments.
Sec. 1204. Funding for the territories.
Sec. 1205. Delay in Community First Choice option.
Sec. 1206. Drug rebates for new formulations of existing drugs.

              Subtitle D--Reducing Fraud, Waste, and Abuse

Sec. 1301. Community mental health centers.
Sec. 1302. Medicare prepayment medical review limitations.
Sec. 1303. CMS-IRS data match to identify fraudulent providers.
Sec. 1304. Funding to fight fraud, waste, and abuse.
Sec. 1305. 90-day period of enhanced oversight for initial claims of 
              DME suppliers.

               Subtitle E--Provisions Relating to Revenue

Sec. 1401. High-cost plan excise tax.
Sec. 1402. Medicare tax.
Sec. 1403. Delay of limitation on health flexible spending arrangements 
              under cafeteria plans.
Sec. 1404. Brand name pharmaceuticals.
Sec. 1405. Excise tax on medical device manufacturers.
Sec. 1406. Health insurance providers.
Sec. 1407. Delay of elimination of deduction for expenses allocable to 
              medicare part D subsidy.
Sec. 1408. Elimination of unintended application of cellulosic biofuel 
              producer credit.
Sec. 1409. Codification of economic substance doctrine and penalties.
Sec. 1410. Time for payment of corporate estimated taxes.
Sec. 1411. No impact on Social Security trust funds.

                      Subtitle F--Other Provisions

Sec. 1501. Community college and career training grant program.

                     TITLE II--EDUCATION AND HEALTH

                         Subtitle A--Education

Sec. 2001. Short title; references.

               Part I--Investing in Students and Families

Sec. 2101. Federal Pell Grants.
Sec. 2102. Student financial assistance.
Sec. 2103. College access challenge grant program.
Sec. 2104. Investment in historically black colleges and universities 
              and minority-serving institutions.

                      Part II--Student Loan Reform

Sec. 2201. Termination of Federal Family Education Loan appropriations.
Sec. 2202. Termination of Federal loan insurance program.
Sec. 2203. Termination of applicable interest rates.
Sec. 2204. Termination of Federal payments to reduce student interest 
              costs.
Sec. 2205. Termination of FFEL PLUS Loans.
Sec. 2206. Federal Consolidation Loans.
Sec. 2207. Termination of Unsubsidized Stafford Loans for middle-income 
              borrowers.
Sec. 2208. Termination of special allowances.
Sec. 2209. Origination of Direct Loans at institutions outside the 
              United States.

[[Page 4446]]

Sec. 2210. Conforming amendments.
Sec. 2211. Terms and conditions of loans.
Sec. 2212. Contracts; mandatory funds.
Sec. 2213. Agreements with State-owned banks.
Sec. 2214. Income-based repayment.

                           Subtitle B--Health

Sec. 2301. Insurance reforms.
Sec. 2302. Drugs purchased by covered entities.
Sec. 2303. Community health centers.

          TITLE I--COVERAGE, MEDICARE, MEDICAID, AND REVENUES

                          Subtitle A--Coverage

     SEC. 1001. TAX CREDITS.

       (a) Premium Tax Credits.--Section 36B of the Internal 
     Revenue Code of 1986, as added by section 1401 of the Patient 
     Protection and Affordable Care Act and amended by section 
     10105 of such Act, is amended--
       (1) in subsection (b)(3)(A)--
       (A) in clause (i), by striking ``with respect to any 
     taxpayer'' and all that follows up to the end period and 
     inserting ``for any taxable year shall be the percentage such 
     that the applicable percentage for any taxpayer whose 
     household income is within an income tier specified in the 
     following table shall increase, on a sliding scale in a 
     linear manner, from the initial premium percentage to the 
     final premium percentage specified in such table for such 
     income tier:

 
 ``In the case of household
   income (expressed as a
  percent of poverty line)     The initial premium    The final premium
 within the following income     percentage is--       percentage is--
            tier:
 
Up to 133%                    2.0%                  2.0%
133% up to 150%               3.0%                  4.0%
150% up to 200%               4.0%                  6.3%
200% up to 250%               6.3%                  8.05%
250% up to 300%               8.05%                 9.5%
300% up to 400%               9.5%                  9.5%''; and
 

       (B) by striking clauses (ii) and (iii), and inserting the 
     following:
       ``(ii) Indexing.--

       ``(I) In general.--Subject to subclause (II), in the case 
     of taxable years beginning in any calendar year after 2014, 
     the initial and final applicable percentages under clause (i) 
     (as in effect for the preceding calendar year after 
     application of this clause) shall be adjusted to reflect the 
     excess of the rate of premium growth for the preceding 
     calendar year over the rate of income growth for the 
     preceding calendar year.
       ``(II) Additional adjustment.--Except as provided in 
     subclause (III), in the case of any calendar year after 2018, 
     the percentages described in subclause (I) shall, in addition 
     to the adjustment under subclause (I), be adjusted to reflect 
     the excess (if any) of the rate of premium growth estimated 
     under subclause (I) for the preceding calendar year over the 
     rate of growth in the consumer price index for the preceding 
     calendar year.
       ``(III) Failsafe.--Subclause (II) shall apply for any 
     calendar year only if the aggregate amount of premium tax 
     credits under this section and cost-sharing reductions under 
     section 1402 of the Patient Protection and Affordable Care 
     Act for the preceding calendar year exceeds an amount equal 
     to 0.504 percent of the gross domestic product for the 
     preceding calendar year.''; and

       (2) in subsection (c)(2)(C)--
       (A) by striking ``9.8 percent'' in clauses (i)(II) and (iv) 
     and inserting ``9.5 percent'', and
       (B) by striking ``(b)(3)(A)(iii)'' in clause (iv) and 
     inserting ``(b)(3)(A)(ii)''.
       (b) Cost Sharing.--Section 1402(c) of the Patient 
     Protection and Affordable Care Act is amended--
       (1) in paragraph (1)(B)(i)--
       (A) in subclause (I), by striking ``90'' and inserting 
     ``94'';
       (B) in subclause (II)--
       (i) by striking ``80'' and inserting ``87''; and
       (ii) by striking ``and''; and
       (C) by striking subclause (III) and inserting the 
     following:

       ``(III) 73 percent in the case of an eligible insured whose 
     household income is more than 200 percent but not more than 
     250 percent of the poverty line for a family of the size 
     involved; and
       ``(IV) 70 percent in the case of an eligible insured whose 
     household income is more than 250 percent but not more than 
     400 percent of the poverty line for a family of the size 
     involved.''; and

       (2) in paragraph (2)--
       (A) in subparagraph (A)--
       (i) by striking ``90'' and inserting ``94''; and
       (ii) by striking ``and'';
       (B) in subparagraph (B)--
       (i) by striking ``80'' and inserting ``87''; and
       (ii) by striking the period and inserting ``; and''; and
       (C) by inserting after subparagraph (B) the following new 
     subparagraph:
       ``(C) in the case of an eligible insured whose household 
     income is more than 200 percent but not more than 250 percent 
     of the poverty line for a family of the size involved, 
     increase the plan's share of the total allowed costs of 
     benefits provided under the plan to 73 percent of such 
     costs.''.

     SEC. 1002. INDIVIDUAL RESPONSIBILITY.

       (a) Amounts.--Section 5000A(c) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act and amended by section 
     10106 of such Act, is amended--
       (1) in paragraph (2)(B)--
       (A) in the matter preceding clause (i), by--
       (i) inserting ``the excess of'' before ``the taxpayer's 
     household income''; and
       (ii) inserting ``for the taxable year over the amount of 
     gross income specified in section 6012(a)(1) with respect to 
     the taxpayer'' before ``for the taxable year'';
       (B) in clause (i), by striking ``0.5'' and inserting 
     ``1.0'';
       (C) in clause (ii), by striking ``1.0'' and inserting 
     ``2.0''; and
       (D) in clause (iii), by striking ``2.0'' and inserting 
     ``2.5''; and
       (2) in paragraph (3)--
       (A) in subparagraph (A), by striking ``$750'' and inserting 
     ``$695'';
       (B) in subparagraph (B), by striking ``$495'' and inserting 
     ``$325''; and
       (C) in subparagraph (D)--
       (i) in the matter preceding clause (i), by striking 
     ``$750'' and inserting ``$695''; and
       (ii) in clause (i), by striking ``$750'' and inserting 
     ``$695''.
       (b) Threshold.--Section 5000A of such Code, as so added and 
     amended, is amended--
       (1) by striking subsection (c)(4)(D); and
       (2) in subsection (e)(2)--
       (A) by striking ``under 100 percent of poverty line'' and 
     inserting ``below filing threshold''; and
       (B) by striking all that follows ``less than'' and 
     inserting ``the amount of gross income specified in section 
     6012(a)(1) with respect to the taxpayer.''.

     SEC. 1003. EMPLOYER RESPONSIBILITY.

       (a) Payment Calculation.--Subparagraph (D) of subsection 
     (d)(2) of section 4980H of the Internal Revenue Code of 1986, 
     as added by section 1513 of the Patient Protection and 
     Affordable Care Act and amended by section 10106 of such Act, 
     is amended to read as follows:
       ``(D) Application of employer size to assessable 
     penalties.--
       ``(i) In general.--The number of individuals employed by an 
     applicable large employer as full-time employees during any 
     month shall be reduced by 30 solely for purposes of 
     calculating--

       ``(I) the assessable payment under subsection (a), or
       ``(II) the overall limitation under subsection (b)(2).

       ``(ii) Aggregation.--In the case of persons treated as 1 
     employer under subparagraph (C)(i), only 1 reduction under 
     subclause (I) or (II) shall be allowed with respect to such 
     persons and such reduction shall be allocated among such 
     persons ratably on the basis of the number of full-time 
     employees employed by each such person.''.
       (b) Applicable Payment Amount.--Section 4980H of such Code, 
     as so added and amended, is amended--
       (1) in the flush text following subsection (c)(1)(B), by 
     striking ``400 percent of the applicable payment amount'' and 
     inserting ``an amount equal to \1/12\ of $3,000'';
       (2) in subsection (d)(1), by striking ``$750'' and 
     inserting ``$2,000''; and
       (3) in subsection (d)(5)(A), in the matter preceding clause 
     (i), by striking ``subsection (b)(2) and (d)(1)'' and 
     inserting ``subsection (b) and paragraph (1)''.
       (c) Counting Part-Time Workers in Setting the Threshold for 
     Employer Responsibility.--Section 4980H(d)(2) of such Code, 
     as so added and amended and as amended by subsection (a), is 
     amended by adding at the end the following new subparagraph:
       ``(E) Full-time equivalents treated as full-time 
     employees.--Solely for purposes of determining whether an 
     employer is an applicable large employer under this 
     paragraph, an employer shall, in addition to the number of 
     full-time employees for any month otherwise determined, 
     include for such month a number of full-time employees 
     determined by dividing the aggregate number of hours of 
     service of employees who are not full-time employees for the 
     month by 120.''.
       (d) Eliminating Waiting Period Assessment.--Section 4980H 
     of such Code, as so added and amended and as amended by the 
     preceding subsections, is amended by striking subsection (b) 
     and redesignating subsections (c), (d), and (e) as 
     subsections (b), (c), and (d), respectively.

     SEC. 1004. INCOME DEFINITIONS.

       (a) Modified Adjusted Gross Income.--
       (1) In general.--The following provisions of the Internal 
     Revenue Code of 1986 are each amended by striking ``modified 
     gross'' each place it appears and inserting ``modified 
     adjusted gross'':
       (A) Clauses (i) and (ii) of section 36B(d)(2)(A), as added 
     by section 1401 of the Patient Protection and Affordable Care 
     Act.
       (B) Section 6103(l)(21)(A)(iv), as added by section 1414 of 
     such Act.
       (C) Clauses (i) and (ii) of section 5000A(c)(4), as added 
     by section 1501(b) of such Act.
       (2) Definition.--
       (A) Section 36B(d)(2)(B) of such Code, as so added, is 
     amended to read as follows:
       ``(B) Modified adjusted gross income.--The term `modified 
     adjusted gross income' means adjusted gross income increased 
     by--

[[Page 4447]]

       ``(i) any amount excluded from gross income under section 
     911, and
       ``(ii) any amount of interest received or accrued by the 
     taxpayer during the taxable year which is exempt from tax.''.
       (B) Section 5000A(c)(4)(C) of such Code, as so added, is 
     amended to read as follows:
       ``(C) Modified adjusted gross income.--The term `modified 
     adjusted gross income' means adjusted gross income increased 
     by--
       ``(i) any amount excluded from gross income under section 
     911, and
       ``(ii) any amount of interest received or accrued by the 
     taxpayer during the taxable year which is exempt from tax.''.
       (b) Modified Adjusted Gross Income Definition.--
       (1) Medicaid.--Section 1902 of the Social Security Act (42 
     U.S.C. 1396a) is amended by striking ``modified gross 
     income'' each place it appears in the text and headings of 
     the following provisions and inserting ``modified adjusted 
     gross income'':
       (A) Paragraph (14) of subsection (e), as added by section 
     2002(a) of the Patient Protection and Affordable Care Act.
       (B) Subsection (gg)(4)(A), as added by section 2001(b) of 
     such Act.
       (2) Chip.--
       (A) State plan requirements.--Section 2102(b)(1)(B)(v) of 
     the Social Security Act (42 U.S.C. 1397bb(b)(1)(B)(v)), as 
     added by section 2101(d)(1) of the Patient Protection and 
     Affordable Care Act, is amended by striking ``modified gross 
     income'' and inserting ``modified adjusted gross income''.
       (B) Plan administration.--Section 2107(e)(1)(E) of the 
     Social Security Act (42 U.S.C. 1397gg(e)(1)(E)), as added by 
     section 2101(d)(2) of the Patient Protection and Affordable 
     Care Act, is amended by striking ``modified gross income'' 
     and inserting ``modified adjusted gross income''.
       (c) No Excess Payments.--Section 36B(f) of the Internal 
     Revenue Code of 1986, as added by section 1401(a) of the 
     Patient Protection and Affordable Care Act, is amended by 
     adding at the end the following new paragraph:
       ``(3) Information requirement.--Each Exchange (or any 
     person carrying out 1 or more responsibilities of an Exchange 
     under section 1311(f)(3) or 1321(c) of the Patient Protection 
     and Affordable Care Act) shall provide the following 
     information to the Secretary and to the taxpayer with respect 
     to any health plan provided through the Exchange:
       ``(A) The level of coverage described in section 1302(d) of 
     the Patient Protection and Affordable Care Act and the period 
     such coverage was in effect.
       ``(B) The total premium for the coverage without regard to 
     the credit under this section or cost-sharing reductions 
     under section 1402 of such Act.
       ``(C) The aggregate amount of any advance payment of such 
     credit or reductions under section 1412 of such Act.
       ``(D) The name, address, and TIN of the primary insured and 
     the name and TIN of each other individual obtaining coverage 
     under the policy.
       ``(E) Any information provided to the Exchange, including 
     any change of circumstances, necessary to determine 
     eligibility for, and the amount of, such credit.
       ``(F) Information necessary to determine whether a taxpayer 
     has received excess advance payments.''.
       (d) Adult Dependents.--
       (1) Exclusion of amounts expended for medical care.--The 
     first sentence of section 105(b) of the Internal Revenue Code 
     of 1986 (relating to amounts expended for medical care) is 
     amended--
       (A) by striking ``and his dependents'' and inserting ``his 
     dependents''; and
       (B) by inserting before the period the following: ``, and 
     any child (as defined in section 152(f)(1)) of the taxpayer 
     who as of the end of the taxable year has not attained age 
     27''.
       (2) Self-employed health insurance deduction.--Section 
     162(l)(1) of such Code is amended to read as follows:
       ``(1) Allowance of deduction.--In the case of a taxpayer 
     who is an employee within the meaning of section 401(c)(1), 
     there shall be allowed as a deduction under this section an 
     amount equal to the amount paid during the taxable year for 
     insurance which constitutes medical care for--
       ``(A) the taxpayer,
       ``(B) the taxpayer's spouse,
       ``(C) the taxpayer's dependents, and
       ``(D) any child (as defined in section 152(f)(1)) of the 
     taxpayer who as of the end of the taxable year has not 
     attained age 27.''.
       (3) Coverage under self-employed deduction.--Section 
     162(l)(2)(B) of such Code is amended by inserting ``, or any 
     dependent, or individual described in subparagraph (D) of 
     paragraph (1) with respect to,'' after ``spouse of''.
       (4) Sick and accident benefits provided to members of a 
     voluntary employees' beneficiary association and their 
     dependents.--Section 501(c)(9) of such Code is amended by 
     adding at the end the following new sentence: ``For purposes 
     of providing for the payment of sick and accident benefits to 
     members of such an association and their dependents, the term 
     `dependent' shall include any individual who is a child (as 
     defined in section 152(f)(1)) of a member who as of the end 
     of the calendar year has not attained age 27.''.
       (5) Medical and other benefits for retired employees.--
     Section 401(h) of such Code is amended by adding at the end 
     the following: ``For purposes of this subsection, the term 
     `dependent' shall include any individual who is a child (as 
     defined in section 152(f)(1)) of a retired employee who as of 
     the end of the calendar year has not attained age 27.''.
       (e) Five Percent Income Disregard for Certain 
     Individuals.--Section 1902(e)(14) of the Social Security Act 
     (42 U.S.C. 1396a(e)(14)), as amended by subsection (b)(1), is 
     further amended--
       (1) in subparagraph (B), by striking ``No type'' and 
     inserting ``Subject to subparagraph (I), no type''; and
       (2) by adding at the end the following new subparagraph:
       ``(I) Treatment of portion of modified adjusted gross 
     income.--For purposes of determining the income eligibility 
     of an individual for medical assistance whose eligibility is 
     determined based on the application of modified adjusted 
     gross income under subparagraph (A), the State shall--
       ``(i) determine the dollar equivalent of the difference 
     between the upper income limit on eligibility for such an 
     individual (expressed as a percentage of the poverty line) 
     and such upper income limit increased by 5 percentage points; 
     and
       ``(ii) notwithstanding the requirement in subparagraph (A) 
     with respect to use of modified adjusted gross income, 
     utilize as the applicable income of such individual, in 
     determining such income eligibility, an amount equal to the 
     modified adjusted gross income applicable to such individual 
     reduced by such dollar equivalent amount.''.

     SEC. 1005. IMPLEMENTATION FUNDING.

       (a) In General.--There is hereby established a Health 
     Insurance Reform Implementation Fund (referred to in this 
     section as the ``Fund'') within the Department of Health and 
     Human Services to carry out the Patient Protection and 
     Affordable Care Act and this Act (and the amendments made by 
     such Acts).
       (b) Funding.--There is appropriated to the Fund, out of any 
     funds in the Treasury not otherwise appropriated, 
     $1,000,000,000 for Federal administrative expenses to carry 
     out such Act (and the amendments made by such Acts).

                          Subtitle B--Medicare

     SEC. 1101. CLOSING THE MEDICARE PRESCRIPTION DRUG ``DONUT 
                   HOLE''.

       (a) Coverage Gap Rebate for 2010.--
       (1) In general.--Section 1860D-42 of the Social Security 
     Act (42 U.S.C. 1395w-152) is amended by adding at the end the 
     following new subsection:
       ``(c) Coverage Gap Rebate for 2010.--
       ``(1) In general.--In the case of an individual described 
     in subparagraphs (A) through (D) of section 1860D-14A(g)(1) 
     who as of the last day of a calendar quarter in 2010 has 
     incurred costs for covered part D drugs so that the 
     individual has exceeded the initial coverage limit under 
     section 1860D-2(b)(3) for 2010, the Secretary shall provide 
     for payment from the Medicare Prescription Drug Account of 
     $250 to the individual by not later than the 15th day of the 
     third month following the end of such quarter.
       ``(2) Limitation.--The Secretary shall provide only 1 
     payment under this subsection with respect to any 
     individual.''.
       (2) Repeal of provision.--Section 3315 of the Patient 
     Protection and Affordable Care Act (including the amendments 
     made by such section) is repealed, and any provision of law 
     amended or repealed by such sections is hereby restored or 
     revived as if such section had not been enacted into law.
       (b) Closing the Donut Hole.--Part D of title XVIII of the 
     Social Security Act (42 U.S.C. 1395w-101 et seq.), as amended 
     by section 3301 of the Patient Protection and Affordable Care 
     Act, is further amended--
       (1) in section 1860D-43--
       (A) in subsection (b), by striking ``July 1, 2010'' and 
     inserting ``January 1, 2011''; and
       (B) in subsection (c)(2), by striking ``July 1, 2010, and 
     ending on December 31, 2010,'' and inserting ``January 1, 
     2011, and December 31, 2011,'';
       (2) in section 1860D-14A--
       (A) in subsection (a)--
       (i) by striking ``July 1, 2010'' and inserting ``January 1, 
     2011''; and
       (ii) by striking ``April 1, 2010'' and inserting ``180 days 
     after the date of the enactment of this section'';
       (B) in subsection (b)(1)(C)--
       (i) in the heading, by striking ``2010 and'';
       (ii) by striking ``July 1, 2010'' and inserting ``January 
     1, 2011''; and
       (iii) by striking ``May 1, 2010'' and inserting ``not later 
     than 30 days after the date of the establishment of a model 
     agreement under subsection (a)'';
       (C) in subsection (c)--
       (i) in paragraph (1)(A)(iii), by striking ``July 1, 2010, 
     and ending on December 31, 2011'' and inserting ``January 1, 
     2011, and ending on December 31, 2011''; and
       (ii) in paragraph (2), by striking ``2010'' and inserting 
     ``2011'';
       (D) in subsection (d)(2)(B), by striking ``July 1, 2010, 
     and ending on December 31, 2010'' and inserting ``January 1, 
     2011, and ending on December 31, 2011''; and
       (E) in subsection (g)(1)--
       (i) in the matter before subparagraph (A), by striking ``an 
     applicable drug'' and inserting ``a covered part D drug'';
       (ii) by adding ``and'' at the end of subparagraph (C);
       (iii) by striking subparagraph (D); and
       (iv) by redesignating subparagraph (E) as subparagraph (D); 
     and

[[Page 4448]]

       (3) in section 1860D-2(b)--
       (A) in paragraph (2)(A), by striking ``The coverage'' and 
     inserting ``Subject to subparagraphs (C) and (D), the 
     coverage'';
       (B) in paragraph (2)(B), by striking ``subparagraph 
     (A)(ii)'' and inserting ``subparagraphs (A)(ii), (C), and 
     (D)'';
       (C) by adding at the end of paragraph (2) the following new 
     subparagraphs:
       ``(C) Coverage for generic drugs in coverage gap.--
       ``(i) In general.--Except as provided in paragraph (4), the 
     coverage for an applicable beneficiary (as defined in section 
     1860D-14A(g)(1)) has coinsurance (for costs above the initial 
     coverage limit under paragraph (3) and below the out-of-
     pocket threshold) for covered part D drugs that are not 
     applicable drugs under section 1860D-14A(g)(2) that is--

       ``(I) equal to the generic-gap coinsurance percentage 
     (specified in clause (ii)) for the year, or
       ``(II) actuarially equivalent (using processes and methods 
     established under section 1860D-11(c)) to an average expected 
     payment of such percentage of such costs for covered part D 
     drugs that are not applicable drugs under section 1860D-
     14A(g)(2).

       ``(ii) Generic-gap coinsurance percentage.--The generic-gap 
     coinsurance percentage specified in this clause for--

       ``(I) 2011 is 93 percent;
       ``(II) 2012 and each succeeding year before 2020 is the 
     generic-gap coinsurance percentage under this clause for the 
     previous year decreased by 7 percentage points; and
       ``(III) 2020 and each subsequent year is 25 percent.

       ``(D) Coverage for applicable drugs in coverage gap.--
       ``(i) In general.--Except as provided in paragraph (4), the 
     coverage for an applicable beneficiary (as defined in section 
     1860D-14A(g)(1)) has coinsurance (for costs above the initial 
     coverage limit under paragraph (3) and below the out-of-
     pocket threshold) for the negotiated price (as defined in 
     section 1860D-14A(g)(6)) of covered part D drugs that are 
     applicable drugs under section 1860D-14A(g)(2) that is--

       ``(I) equal to the difference between the applicable gap 
     percentage (specified in clause (ii) for the year) and the 
     discount percentage specified in section 1860D-14A(g)(4)(A) 
     for such applicable drugs, or
       ``(II) actuarially equivalent (using processes and methods 
     established under section 1860D-11(c)) to an average expected 
     payment of such percentage of such costs, for covered part D 
     drugs that are applicable drugs under section 1860D-
     14A(g)(2).

       ``(ii) Applicable gap percentage.--The applicable gap 
     percentage specified in this clause for--

       ``(I) 2013 and 2014 is 97.5 percent;
       ``(II) 2015 and 2016 is 95 percent;
       ``(III) 2017 is 90 percent;
       ``(IV) 2018 is 85 percent;
       ``(V) 2019 is 80 percent; and
       ``(VI) 2020 and each subsequent year is 75 percent.'';

       (D) in paragraph (3)(A), as restored under subsection 
     (a)(2), by striking ``paragraph (4)'' and inserting 
     ``paragraphs (2)(C), (2)(D), and (4)'';
       (E) in paragraph (4)(E), by inserting before the period at 
     the end the following: ``, except that incurred costs shall 
     not include the portion of the negotiated price that 
     represents the reduction in coinsurance resulting from the 
     application of paragraph (2)(D)''; and
       (4) in section 1860D-22(a)(2)(A), by inserting before the 
     period at the end the following: ``, not taking into account 
     the value of any discount or coverage provided during the gap 
     in prescription drug coverage that occurs between the initial 
     coverage limit under section 1860D-2(b)(3) during the year 
     and the out-of-pocket threshold specified in section 1860D-
     2(b)(4)(B)''.
       (c) Conforming Amendment to AMP Under Medicaid.--Section 
     1927(k)(1)(B)(i) of the Social Security Act (42 U.S.C. 1396r-
     8(k)(1)(B)(i)), as amended by section 2503(a)(2)(B) of the 
     Patient Protection and Affordable Care Act, is amended--
       (1) by striking ``and'' at the end of subclause (III);
       (2) by striking the period at the end of subclause (IV); 
     and
       (3) by adding at the end the following new subclause:

       ``(V) discounts provided by manufacturers under section 
     1860D-14A.''.

       (d) Reducing Growth Rate of Out-of-pocket Cost Threshold.--
     Section 1860D-2(b) of the Social Security Act (42 U.S.C. 
     1395w-102(b)) is amended--
       (1) in paragraph (4)(B)(i)--
       (A) in subclause (I), by striking ``or'' at the end;
       (B) by redesignating subclause (II) as subclause (VI); and
       (C) by inserting after subclause (I) the following new 
     subclauses:
       ``(II) for each of years 2007 through 2013, is equal to the 
     amount specified in this subparagraph for the previous year, 
     increased by the annual percentage increase described in 
     paragraph (6) for the year involved;
       ``(III) for 2014 and 2015, is equal to the amount specified 
     in this subparagraph for the previous year, increased by the 
     annual percentage increase described in paragraph (6) for the 
     year involved, minus 0.25 percentage point;
       ``(IV) for each of years 2016 through 2019, is equal to the 
     amount specified in this subparagraph for the previous year, 
     increased by the lesser of--

       ``(aa) the annual percentage increase described in 
     paragraph (7) for the year involved, plus 2 percentage 
     points; or
       ``(bb) the annual percentage increase described in 
     paragraph (6) for the year;

       ``(V) for 2020, is equal to the amount that would have been 
     applied under this subparagraph for 2020 if the amendments 
     made by section 1101(d)(1) of the Health Care and Education 
     Reconciliation Act of 2010 had not been enacted; or''; and
       (2) by adding at the end the following new paragraph:
       (7) Additional annual percentage increase.--The annual 
     percentage increase specified in this paragraph for a year is 
     equal to the annual percentage increase in the consumer price 
     index for all urban consumers (United States city average) 
     for the 12-month period ending in July of the previous 
     year.''.

     SEC. 1102. MEDICARE ADVANTAGE PAYMENTS.

       (a) Repeal.--Effective as if included in the enactment of 
     the Patient Protection and Affordable Care Act, sections 3201 
     and 3203 of such Act (and the amendments made by such 
     sections) are repealed.
       (b) Phase-in of Modified Benchmarks.--Section 1853 of the 
     Social Security Act (42 U.S.C. 1395w-23) is amended--
       (1) in subsection (j)(1)(A), by striking ``(or, beginning 
     with 2007, \1/12\ of the applicable amount determined under 
     subsection (k)(1)) for the area for the year'' and inserting 
     `` for the area for the year (or, for 2007, 2008, 2009, and 
     2010, \1/12\ of the applicable amount determined under 
     subsection (k)(1) for the area for the year; for 2011, \1/12\ 
     of the applicable amount determined under subsection (k)(1) 
     for the area for 2010; and, beginning with 2012, \1/12\ of 
     the blended benchmark amount determined under subsection 
     (n)(1) for the area for the year)''; and
       (2) by adding at the end the following new subsection:
       ``(n) Determination of Blended Benchmark Amount.--
       ``(1) In general.--For purposes of subsection (j), subject 
     to paragraphs (3), (4), and (5), the term `blended benchmark 
     amount' means for an area--
       ``(A) for 2012 the sum of--
       ``(i) \1/2\ of the applicable amount for the area and year; 
     and
       ``(ii) \1/2\ of the amount specified in paragraph (2)(A) 
     for the area and year; and
       ``(B) for a subsequent year the amount specified in 
     paragraph (2)(A) for the area and year.
       ``(2) Specified amount.--
       ``(A) In general.--The amount specified in this 
     subparagraph for an area and year is the product of--
       ``(i) the base payment amount specified in subparagraph (E) 
     for the area and year adjusted to take into account the 
     phase-out in the indirect costs of medical education from 
     capitation rates described in subsection (k)(4); and
       ``(ii) the applicable percentage for the area for the year 
     specified under subparagraph (B).
       ``(B) Applicable percentage.--Subject to subparagraph (D), 
     the applicable percentage specified in this subparagraph for 
     an area for a year in the case of an area that is ranked--
       ``(i) in the highest quartile under subparagraph (C) for 
     the previous year is 95 percent;
       ``(ii) in the second highest quartile under such 
     subparagraph for the previous year is 100 percent;
       ``(iii) in the third highest quartile under such 
     subparagraph for the previous year is 107.5 percent; or
       ``(iv) in the lowest quartile under such subparagraph for 
     the previous year is 115 percent.
       ``(C) Periodic ranking.--For purposes of this paragraph in 
     the case of an area located--
       ``(i) in 1 of the 50 States or the District of Columbia, 
     the Secretary shall rank such area in each year specified 
     under subsection (c)(1)(D)(ii) based upon the level of the 
     amount specified in subparagraph (A)(i) for such areas; or
       ``(ii) in a territory, the Secretary shall rank such areas 
     in each such year based upon the level of the amount 
     specified in subparagraph (A)(i) for such area relative to 
     quartile rankings computed under clause (i).
       ``(D) 1-year transition for changes in applicable 
     percentage.--If, for a year after 2012, there is a change in 
     the quartile in which an area is ranked compared to the 
     previous year, the applicable percentage for the area in the 
     year shall be the average of--
       ``(i) the applicable percentage for the area for the 
     previous year; and
       ``(ii) the applicable percentage that would otherwise apply 
     for the area for the year.
       ``(E) Base payment amount.--Subject to subparagraph (F), 
     the base payment amount specified in this subparagraph--
       ``(i) for 2012 is the amount specified in subsection 
     (c)(1)(D) for the area for the year; or
       ``(ii) for a subsequent year that--

       ``(I) is not specified under subsection (c)(1)(D)(ii), is 
     the base amount specified in this subparagraph for the area 
     for the previous year, increased by the national per capita 
     MA growth percentage, described in subsection (c)(6) for that 
     succeeding year, but not taking into account any adjustment 
     under subparagraph (C) of such subsection for a year before 
     2004; and
       ``(II) is specified under subsection (c)(1)(D)(ii), is the 
     amount specified in subsection (c)(1)(D) for the area for the 
     year.

       ``(F) Application of indirect medical education phase-
     out.--The base payment amount specified in subparagraph (E) 
     for a year shall be adjusted in the same manner under 
     paragraph (4) of subsection (k) as the applicable amount is 
     adjusted under such subsection.
       ``(3) Alternative phase-ins.--

[[Page 4449]]

       ``(A) 4-year phase-in for certain areas.--If the difference 
     between the applicable amount (as defined in subsection (k)) 
     for an area for 2010 and the projected 2010 benchmark amount 
     (as defined in subparagraph (C)) for the area is at least $30 
     but less than $50, the blended benchmark amount for the area 
     is--
       ``(i) for 2012 the sum of--

       ``(I) \3/4\ of the applicable amount for the area and year; 
     and
       ``(II) \1/4\ of the amount specified in paragraph (2)(A) 
     for the area and year;

       ``(ii) for 2013 the sum of--

       ``(I) \1/2\ of the applicable amount for the area and year; 
     and
       ``(II) \1/2\ of the amount specified in paragraph (2)(A) 
     for the area and year;

       ``(iii) for 2014 the sum of--

       ``(I) \1/4\ of the applicable amount for the area and year; 
     and
       ``(II) \3/4\ of the amount specified in paragraph (2)(A) 
     for the area and year; and

       ``(iv) for a subsequent year the amount specified in 
     paragraph (2)(A) for the area and year.
       ``(B) 6-year phase-in for certain areas.--If the difference 
     between the applicable amount (as defined in subsection (k)) 
     for an area for 2010 and the projected 2010 benchmark amount 
     (as defined in subparagraph (C)) for the area is at least 
     $50, the blended benchmark amount for the area is--
       ``(i) for 2012 the sum of--

       ``(I) \5/6\ of the applicable amount for the area and year; 
     and
       ``(II) \1/6\ of the amount specified in paragraph (2)(A) 
     for the area and year;

       ``(ii) for 2013 the sum of--

       ``(I) \2/3\ of the applicable amount for the area and year; 
     and
       ``(II) \1/3\ of the amount specified in paragraph (2)(A) 
     for the area and year;

       ``(iii) for 2014 the sum of--

       ``(I) \1/2\ of the applicable amount for the area and year; 
     and
       ``(II) \1/2\ of the amount specified in paragraph (2)(A) 
     for the area and year;

       ``(iv) for 2015 the sum of--

       ``(I) \1/3\ of the applicable amount for the area and year; 
     and
       ``(II) \2/3\ of the amount specified in paragraph (2)(A) 
     for the area and year; and

       ``(v) for 2016 the sum of--

       ``(I) \1/6\ of the applicable amount for the area and year; 
     and
       ``(II) \5/6\ of the amount specified in paragraph (2)(A) 
     for the area and year; and

       ``(vi) for a subsequent year the amount specified in 
     paragraph (2)(A) for the area and year.
       ``(C) Projected 2010 benchmark amount.--The projected 2010 
     benchmark amount described in this subparagraph for an area 
     is equal to the sum of--
       ``(i) \1/2\ of the applicable amount (as defined in 
     subsection (k)) for the area for 2010; and
       ``(ii) \1/2\ of the amount specified in paragraph (2)(A) 
     for the area for 2010 but determined as if there were 
     substituted for the applicable percentage specified in clause 
     (ii) of such paragraph the sum of--

       ``(I) the applicable percent that would be specified under 
     subparagraph (B) of paragraph (2) (determined without regard 
     to subparagraph (D) of such paragraph) for the area for 2010 
     if any reference in such paragraph to `the previous year' 
     were deemed a reference to 2010; and
       ``(II) the applicable percentage increase that would apply 
     to a qualifying plan in the area under subsection (o) as if 
     any reference in such subsection to 2012 were deemed a 
     reference to 2010 and as if the determination of a qualifying 
     county under paragraph (3)(B) of such subsection were made 
     for 2010.

       ``(4) Cap on benchmark amount.--In no case shall the 
     blended benchmark amount for an area for a year (determined 
     taking into account subsection (o)) be greater than the 
     applicable amount that would (but for the application of this 
     subsection) be determined under subsection (k)(1) for the 
     area for the year.
       ``(5) Non-application to pace plans.--This subsection shall 
     not apply to payments to a PACE program under section 
     1894.''.
       (c) Applicable Percentage Quality Increases.--Section 1853 
     of such Act (42 U.S.C. 1395w-23), as amended by subsection 
     (b), is amended--
       (1) in subsection (j), by inserting ``subject to subsection 
     (o),'' after ``For purposes of this part,'';
       (2) in subsection (n)(2)(B), as added by subsection (b), by 
     inserting ``, subject to subsection (o)'' after ``as 
     follows''; and
       (3) by adding at the end the following new subsection:
       ``(o) Applicable Percentage Quality Increases.--
       ``(1) In general.--Subject to the succeeding paragraphs, in 
     the case of a qualifying plan with respect to a year 
     beginning with 2012, the applicable percentage under 
     subsection (n)(2)(B) shall be increased on a plan or contract 
     level, as determined by the Secretary--
       ``(A) for 2012, by 1.5 percentage points;
       ``(B) for 2013, by 3.0 percentage points; and
       ``(C) for 2014 or a subsequent year, by 5.0 percentage 
     points.
       ``(2) Increase for qualifying plans in qualifying 
     counties.--The increase applied under paragraph (1) for a 
     qualifying plan located in a qualifying county for a year 
     shall be doubled.
       ``(3) Qualifying plans and qualifying county defined; 
     application of increases to low enrollment and new plans.--
     For purposes of this subsection:
       ``(A) Qualifying plan.--
       ``(i) In general.--The term `qualifying plan' means, for a 
     year and subject to paragraph (4), a plan that had a quality 
     rating under paragraph (4) of 4 stars or higher based on the 
     most recent data available for such year.
       ``(ii) Application of increases to low enrollment plans.--

       ``(I) 2012.--For 2012, the term `qualifying plan' includes 
     an MA plan that the Secretary determines is not able to have 
     a quality rating under paragraph (4) because of low 
     enrollment.
       ``(II) 2013 and subsequent years.--For 2013 and subsequent 
     years, for purposes of determining whether an MA plan with 
     low enrollment (as defined by the Secretary) is included as a 
     qualifying plan, the Secretary shall establish a method to 
     apply to MA plans with low enrollment (as defined by the 
     Secretary) the computation of quality rating and the rating 
     system under paragraph (4).

       ``(iii) Application of increases to new plans.--

       ``(I) In general.--A new MA plan that meets criteria 
     specified by the Secretary shall be treated as a qualifying 
     plan, except that in applying paragraph (1), the applicable 
     percentage under subsection (n)(2)(B) shall be increased--

       ``(aa) for 2012, by 1.5 percentage points;
       ``(bb) for 2013, by 2.5 percentage points; and
       ``(cc) for 2014 or a subsequent year, by 3.5 percentage 
     points.

       ``(II) New ma plan defined.--The term `new MA plan' means, 
     with respect to a year, a plan offered by an organization or 
     sponsor that has not had a contract as a Medicare Advantage 
     organization in the preceding 3-year period.

       ``(B) Qualifying county.--The term `qualifying county' 
     means, for a year, a county--
       ``(i) that has an MA capitation rate that, in 2004, was 
     based on the amount specified in subsection (c)(1)(B) for a 
     Metropolitan Statistical Area with a population of more than 
     250,000;
       ``(ii) for which, as of December 2009, of the Medicare 
     Advantage eligible individuals residing in the county at 
     least 25 percent of such individuals were enrolled in 
     Medicare Advantage plans; and
       ``(iii) that has per capita fee-for-service spending that 
     is lower than the national monthly per capita cost for 
     expenditures for individuals enrolled under the original 
     medicare fee-for-service program for the year.
       ``(4) Quality determinations for application of increase.--
       ``(A) Quality determination.--The quality rating for a plan 
     shall be determined according to a 5-star rating system 
     (based on the data collected under section 1852(e)).
       ``(B) Plans that failed to report.--An MA plan which does 
     not report data that enables the Secretary to rate the plan 
     for purposes of this paragraph shall be counted as having a 
     rating of fewer than 3.5 stars.
       ``(5) Exception for pace plans.--This subsection shall not 
     apply to payments to a PACE program under section 1894.''.
       (4) Determination of medicare part d low-income benchmark 
     premium.--Section 1860D-14(b)(2)(B)(iii) of the Social 
     Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) as amended 
     by section 3302 of the Patient Protection and Affordable Care 
     Act, is amended by striking ``, determined without regard to 
     any reduction in such premium as a result of any beneficiary 
     rebate under section 1854(b)(1)(C) or bonus payment under 
     section 1853(n)'' and inserting the following: ``and 
     determined before the application of the monthly rebate 
     computed under section 1854(b)(1)(C)(i) for that plan and 
     year involved and, in the case of a qualifying plan, before 
     the application of the increase under section 1853(o) for 
     that plan and year involved''.
       (d) Beneficiary Rebates.--Section 1854(b)(1)(C) of such Act 
     (42 U.S.C. 1395w-24(b)(1)(C)), as amended by section 3202(b) 
     of the Patient Protection and Affordable Care Act, is further 
     amended--
       (1) in clause (i), by inserting ``(or the applicable rebate 
     percentage specified in clause (iii) in the case of plan 
     years beginning on or after January 1, 2012)'' after ``75 
     percent''; and
       (2) by striking clause (iii), by redesignating clauses (iv) 
     and (v) as clauses (vii) and (viii), respectively, and by 
     inserting after clause (ii) the following new clauses:
       ``(iii) Applicable rebate percentage.--The applicable 
     rebate percentage specified in this clause for a plan for a 
     year, based on the system under section 1853(o)(4)(A), is the 
     sum of--

       ``(I) the product of the old phase-in proportion for the 
     year under clause (iv) and 75 percent; and
       ``(II) the product of the new phase-in proportion for the 
     year under clause (iv) and the final applicable rebate 
     percentage under clause (v).

       ``(iv) Old and new phase-in proportions.--For purposes of 
     clause (iv)--

       ``(I) for 2012, the old phase-in proportion is \2/3\ and 
     the new phase-in proportion is \1/3\;
       ``(II) for 2013, the old phase-in proportion is \1/3\ and 
     the new phase-in proportion is \2/3\; and
       ``(III) for 2014 and any subsequent year, the old phase-in 
     proportion is 0 and the new phase-in proportion is 1.

       ``(v) Final applicable rebate percentage.--Subject to 
     clause (vi), the final applicable rebate percentage under 
     this clause is--

       ``(I) in the case of a plan with a quality rating under 
     such system of at least 4.5 stars, 70 percent;
       ``(II) in the case of a plan with a quality rating under 
     such system of at least 3.5 stars and less than 4.5 stars, 65 
     percent; and
       ``(III) in the case of a plan with a quality rating under 
     such system of less than 3.5 stars, 50 percent.

[[Page 4450]]

       ``(vi) Treatment of low enrollment and new plans.--For 
     purposes of clause (v)--

       ``(I) for 2012, in the case of a plan described in 
     subclause (I) of subsection (o)(3)(A)(ii), the plan shall be 
     treated as having a rating of 4.5 stars; and
       ``(II) for 2012 or a subsequent year, in the case of a new 
     MA plan (as defined under subclause (III) of subsection 
     (o)(3)(A)(iii))) that is treated as a qualifying plan 
     pursuant to subclause (I) of such subsection, the plan shall 
     be treated as having a rating of 3.5 stars.''.

       (e) Coding Intensity Adjustment.--Section 1853(a)(1)(C)(ii) 
     of such Act (42 U.S.C. 1395w-23(a)(1)(C)(ii)) is amended--
       (1) in the heading, by striking ``during phaseout of budget 
     neutrality factor'' and inserting ``of coding adjustment'';
       (2) in the matter before subclause (I), by striking 
     ``through 2010'' and inserting ``and each subsequent year''; 
     and
       (3) in subclause (II)--
       (A) in the first sentence, by inserting ``annually'' before 
     ``conduct an analysis'';
       (B) in the second sentence--
       (i) by inserting ``on a timely basis'' after ``are 
     incorporated''; and
       (ii) by striking ``only for 2008, 2009, and 2010'' and 
     inserting ``for 2008 and subsequent years'';
       (C) in the third sentence, by inserting ``and updated as 
     appropriate'' before the period at the end; and
       (D) by adding at the end the following new subclauses:

       ``(III) In calculating each year's adjustment, the 
     adjustment factor shall be for 2014, not less than the 
     adjustment factor applied for 2010, plus 1.3 percentage 
     points; for each of years 2015 through 2018, not less than 
     the adjustment factor applied for the previous year, plus 
     0.25 percentage point; and for 2019 and each subsequent year, 
     not less than 5.7 percent.
       ``(IV) Such adjustment shall be applied to risk scores 
     until the Secretary implements risk adjustment using Medicare 
     Advantage diagnostic, cost, and use data.''.

       (f) Repeal of Comparative Cost Adjustment Program.--Section 
     1860C-1 of the Social Security Act (42 U.S.C. 1395w-29), as 
     added by section 241(a) of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173), is repealed.

     SEC. 1103. SAVINGS FROM LIMITS ON MA PLAN ADMINISTRATIVE 
                   COSTS.

       Section 1857(e) of the Social Security Act (42 U.S.C. 
     1395w-27(e)) is amended by adding at the end the following 
     new paragraph:
       ``(4) Requirement for minimum medical loss ratio.--If the 
     Secretary determines for a contract year (beginning with 
     2014) that an MA plan has failed to have a medical loss ratio 
     of at least .85--
       ``(A) the MA plan shall remit to the Secretary an amount 
     equal to the product of--
       ``(i) the total revenue of the MA plan under this part for 
     the contract year; and
       ``(ii) the difference between .85 and the medical loss 
     ratio;
       ``(B) for 3 consecutive contract years, the Secretary shall 
     not permit the enrollment of new enrollees under the plan for 
     coverage during the second succeeding contract year; and
       ``(C) the Secretary shall terminate the plan contract if 
     the plan fails to have such a medical loss ratio for 5 
     consecutive contract years.

     SEC. 1104. DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS.

       Section 1886(r) of the Social Security Act (42 U.S.C. 
     1395ww(r)), as added by section 3133 of the Patient 
     Protection and Affordable Care Act and as amended by section 
     10316 of such Act, is amended--
       (1) in paragraph (1), by striking ``2015'' and inserting 
     ``2014''; and
       (2) in paragraph (2)--
       (A) in the matter preceding subparagraph (A), by striking 
     ``2015'' and inserting ``2014'';
       (B) in subparagraph (B)(i)--
       (i) in the heading, by inserting ``2014,'' after ``years'';
       (ii) in the matter preceding subclause (I), by inserting 
     ``2014,'' after ``each of fiscal years'';
       (iii) in subclause (I), by striking ``on such Act'' and 
     inserting ``on the Health Care and Education Reconciliation 
     Act of 2010''; and
       (iv) in the matter following subclause (II), by striking 
     ``minus 1.5 percentage points'' and inserting ``minus 0.1 
     percentage points for fiscal year 2014 and minus 0.2 
     percentage points for each of fiscal years 2015, 2016, and 
     2017''; and
       (C) in subparagraph (B)(ii), in the matter following 
     subclause (II), by striking ``and, for each of 2018 and 2019, 
     minus 1.5 percentage points'' and inserting ``minus 0.2 
     percentage points for each of fiscal years 2018 and 2019''.

     SEC. 1105. MARKET BASKET UPDATES.

       (a) IPPS.--Section 1886(b)(3)(B) of the Social Security Act 
     (42 U.S.C. 1395ww(b)(3)(B)), as amended by sections 
     3401(a)(4) and 10319(a) of the Patient Protection and 
     Affordable Care Act, is amended--
       (1) in clause (xii)--
       (A) by placing the subclause (II) (inserted by section 
     10319(a)(3) of the Patient Protection and Affordable Care 
     Act) immediately after subclause (I) and, in such subclause 
     (II), by striking ``and'' at the end; and
       (B) by striking subclause (III) and inserting the 
     following:
       ``(III) for fiscal year 2014, by 0.3 percentage point;
       ``(IV) for each of fiscal years 2015 and 2016, by 0.2 
     percentage point; and
       ``(V) for each of fiscal years 2017, 2018, and 2019, by 
     0.75 percentage point.''; and
       (2) by striking clause (xiii).
       (b) Long-Term Care Hospitals.--Section 1886(m)(4) of the 
     Social Security Act (42 U.S.C. 1395ww(m)(4)), as added by 
     section 3401(c) of the Patient Protection and Affordable Care 
     Act and amended by section 10319(b) of such Act, is amended--
       (1) in subparagraph (A)--
       (A) in clause (iii), by striking ``and'' at the end; and
       (B) by striking clause (iv) and inserting the following:
       ``(iv) for rate year 2014, 0.3 percentage point;
       ``(v) for each of rate years 2015 and 2016, 0.2 percentage 
     point; and
       ``(vi) for each of rate years 2017, 2018, and 2019, 0.75 
     percentage point.'';
       (2) by striking subparagraph (B); and
       (3) by striking ``(4) Other adjustment.--'' and all that 
     follows through ``For purposes'' and inserting ``(4) Other 
     adjustment.--For purposes'' (and redesignating clauses (i) 
     through (vi) as subparagraphs (A) through (F), respectively, 
     with appropriate indentation).
       (c) Inpatient Rehabilitation Facilities.--Section 
     1886(j)(3)(D) of the Social Security Act (42 U.S.C. 
     1395ww(j)(3)(D)), as added by section 3401(d)(2) of the 
     Patient Protection and Affordable Care Act and amended by 
     section 10319(c) of such Act, is amended--
       (1) in clause (i)--
       (A) by placing the subclause (II) (inserted by section 
     10319(c)(3) of the Patient Protection and Affordable Care 
     Act) immediately after subclause (I) and, in such subclause 
     (II), by striking ``and'' at the end; and
       (B) by striking subclause (III) and inserting the 
     following:

       ``(III) for fiscal year 2014, 0.3 percentage point;
       ``(IV) for each of fiscal years 2015 and 2016, 0.2 
     percentage point; and
       ``(V) for each of fiscal years 2017, 2018, and 2019, 0.75 
     percentage point.'';

       (2) by striking clause (ii); and
       (3) by striking ``(D) Other adjustment.--'' and all that 
     follows through ``For purposes'' and inserting ``(D) Other 
     adjustment.--For purposes'' (and redesignating subclauses (I) 
     through (V) as clauses (i) through (v), respectively, with 
     appropriate indentation).
       (d) Psychiatric Hospitals.--Section 1886(s)(3) of the 
     Social Security Act, as added by section 3401(f) of the 
     Patient Protection and Affordable Care Act and amended by 
     section 10319(e) of such Act, is amended--
       (1) in subparagraph (A)--
       (A) by placing the clause (ii) (inserted by section 
     10319(e)(3) of the Patient Protection and Affordable Care 
     Act) immediately after clause (i) and, in such clause (ii), 
     by striking ``and'' at the end; and
       (B) by striking clause (iii) and inserting the following:
       ``(iii) for the rate year beginning in 2014, 0.3 percentage 
     point;
       ``(iv) for each of the rate years beginning in 2015 and 
     2016, 0.2 percentage point; and
       ``(v) for each of the rate years beginning in 2017, 2018, 
     and 2019, 0.75 percentage point.'';
       (2) by striking subparagraph (B); and
       (3) by striking ``(3) Other adjustment.--'' and all that 
     follows through ``For purposes'' and inserting ``(3) Other 
     adjustment.--For purposes'' (and redesignating clauses (i) 
     through (v) as subparagraphs (A) through (E), respectively, 
     with appropriate indentation).
       (e) Outpatient Hospitals.--Section 1833(t)(3)(G) of the 
     Social Security Act (42 U.S.C. 1395l(t)(3)(G)), as added by 
     section 3401(i)(2) of the Patient Protection and Affordable 
     Care Act and amended by section 10319(g) of such Act, is 
     amended--
       (1) in clause (i)--
       (A) by placing the subclause (II) (inserted by section 
     10319(g)(3) of the Patient Protection and Affordable Care 
     Act) immediately after subclause (I) and, in such subclause 
     (II), by striking ``and'' at the end; and
       (B) by striking subclause (III) and inserting the 
     following:

       ``(III) for 2014, 0.3 percentage point;
       ``(IV) for each of 2015 and 2016, 0.2 percentage point; and
       ``(V) for each of 2017, 2018, and 2019, 0.75 percentage 
     point.'';

       (2) by striking clause (ii); and
       (3) by striking ``(G) Other adjustment.--'' and all that 
     follows through ``For purposes'' and inserting ``(G) Other 
     adjustment.--For purposes'' (and redesignating subclauses (I) 
     through (V) as clauses (i) through (v), respectively, with 
     appropriate indentation).

     SEC. 1106. PHYSICIAN OWNERSHIP-REFERRAL.

       Section 1877(i) of the Social Security Act (42 U.S.C. 
     1395nn(i)), as added by section 6001(a)(3) of the Patient 
     Protection and Affordable Care Act and as amended by section 
     10601(a) of such Act, is amended--
       (1) in paragraph (1)(A)(i), by striking ``August 1, 2010'' 
     and inserting ``December 31, 2010''; and
       (2) in paragraph (3)--
       (A) in subparagraph (A)(i), by striking ``an applicable 
     hospital (as defined in subparagraph (E))'' and inserting ``a 
     hospital that is an applicable hospital (as defined in 
     subparagraph (E)) or is a high Medicaid facility described in 
     subparagraph (F)'';
       (B) in subparagraph (C)(iii), by inserting after ``date of 
     enactment of this subsection'' the following: ``(or, in the 
     case of a hospital that did not have a provider agreement in 
     effect as of such date but does have such an agreement in 
     effect on December 31, 2010, the effective date of such 
     provider agreement)'';
       (C) by redesignating subparagraphs (F) through (H) as 
     subparagraphs (G) through (I), respectively; and

[[Page 4451]]

       (D) by inserting after subparagraph (E) the following new 
     subparagraph:
       ``(F) High medicaid facility described.--A high Medicaid 
     facility described in this subparagraph is a hospital that--
       ``(i) is not the sole hospital in a county;
       ``(ii) with respect to each of the 3 most recent years for 
     which data are available, has an annual percent of total 
     inpatient admissions that represent inpatient admissions 
     under title XIX that is estimated to be greater than such 
     percent with respect to such admissions for any other 
     hospital located in the county in which the hospital is 
     located; and
       ``(iii) meets the conditions described in subparagraph 
     (E)(iii).''.

     SEC. 1107. PAYMENT FOR IMAGING SERVICES.

       Section 1848 of the Social Security Act (42 U.S.C. 1395w-
     4), as amended by section 3135(a) of the Patient Protection 
     and Affordable Care Act, is amended--
       (1) in subsection (b)(4)--
       (A) in subparagraph (B), by striking ``this paragraph'' and 
     inserting ``subparagraph (A)''; and
       (B) by amending subparagraph (C) to read as follows:
       ``(C) Adjustment in imaging utilization rate.--With respect 
     to fee schedules established for 2011 and subsequent years, 
     in the methodology for determining practice expense relative 
     value units for expensive diagnostic imaging equipment under 
     the final rule published by the Secretary in the Federal 
     Register on November 25, 2009 (42 CFR 410, et al.), the 
     Secretary shall use a 75 percent assumption instead of the 
     utilization rates otherwise established in such final 
     rule.''; and
       (2) in subsection (c)(2)(B)(v), by striking subclauses 
     (III), (IV), and (V) and inserting the following new 
     subclause:

       ``(III) Change in utilization rate for certain imaging 
     services.--Effective for fee schedules established beginning 
     with 2011, reduced expenditures attributable to the change in 
     the utilization rate applicable to 2011, as described in 
     subsection (b)(4)(C).''.

     SEC. 1108. PE GPCI ADJUSTMENT FOR 2010.

       Effective as if included in the enactment of the Patient 
     Protection and Affordable Care Act, section 1848(e)(1)(II)(i) 
     of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(H)(i)), 
     as added by section 3102(b)(2) of the Patient Protection and 
     Affordable Care Act, is amended by striking ``\3/4\'' and 
     inserting ``\1/2\''.

     SEC. 1109. PAYMENT FOR QUALIFYING HOSPITALS.

       (a) In General.--From the amount available under subsection 
     (b), the Secretary of Health and Human Services shall provide 
     for a payment to qualifying hospitals (as defined in 
     subsection (d)) for fiscal years 2011 and 2012 of the amount 
     determined under subsection (c).
       (b) Amounts Available.--There shall be available from the 
     Federal Hospital Insurance Trust Fund $400,000,000 for 
     payments under this section for fiscal years 2011 and 2012.
       (c) Payment Amount.--The amount of payment under this 
     section for a qualifying hospital shall be determined, in a 
     manner consistent with the amount available under subsection 
     (b), in proportion to the portion of the amount of the 
     aggregate payments under section 1886(d) of the Social 
     Security Act to the hospital for fiscal year 2009 bears to 
     the sum of all such payments to all qualifying hospitals for 
     such fiscal year.
       (d) Qualifying Hospital Defined.--In this section, the term 
     ``qualifying hospital'' means a subsection (d) hospital (as 
     defined for purposes of section 1886(d) of the Social 
     Security Act) that is located in a county that ranks, based 
     upon its ranking in age, sex, and race adjusted spending for 
     benefits under parts A and B under title XVIII of such Act 
     per enrollee, within the lowest quartile of such counties in 
     the United States.

                          Subtitle C--Medicaid

     SEC. 1201. FEDERAL FUNDING FOR STATES.

       Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
     as amended by sections 2001(a)(3) and 10201(c) of the Patient 
     Protection and Affordable Care Act, is amended--
       (1) in subsection (y)--
       (A) by redesignating subclause (II) of paragraph (1)(B)(ii) 
     as paragraph (5) of subsection (z) and realigning the left 
     margins accordingly; and
       (B) by striking paragraph (1) and inserting the following:
       ``(1) Amount of increase.--Notwithstanding subsection (b), 
     the Federal medical assistance percentage for a State that is 
     one of the 50 States or the District of Columbia, with 
     respect to amounts expended by such State for medical 
     assistance for newly eligible individuals described in 
     subclause (VIII) of section 1902(a)(10)(A)(i), shall be equal 
     to--
       ``(A) 100 percent for calendar quarters in 2014, 2015, and 
     2016;
       ``(B) 95 percent for calendar quarters in 2017;
       ``(C) 94 percent for calendar quarters in 2018;
       ``(D) 93 percent for calendar quarters in 2019; and
       ``(E) 90 percent for calendar quarters in 2020 and each 
     year thereafter.''; and
       (2) in subsection (z)--
       (A) in paragraph (1), by striking ``September 30, 2019'' 
     and inserting ``December 31, 2015'' and by striking 
     ``subsection (y)(1)(B)(ii)(II)'' and inserting ``paragraph 
     (3)'';
       (B) by striking paragraphs (2) through (4) and inserting 
     the following:
       ``(2)(A) For calendar quarters in 2014 and each year 
     thereafter, the Federal medical assistance percentage 
     otherwise determined under subsection (b) for an expansion 
     State described in paragraph (3) with respect to medical 
     assistance for individuals described in section 
     1902(a)(10)(A)(i)(VIII) who are nonpregnant childless adults 
     with respect to whom the State may require enrollment in 
     benchmark coverage under section 1937 shall be equal to the 
     percent specified in subparagraph (B)(i) for such year.
       ``(B)(i) The percent specified in this subparagraph for a 
     State for a year is equal to the Federal medical assistance 
     percentage (as defined in the first sentence of subsection 
     (b)) for the State increased by a number of percentage points 
     equal to the transition percentage (specified in clause (ii) 
     for the year) of the number of percentage points by which--
       ``(I) such Federal medical assistance percentage for the 
     State, is less than
       ``(II) the percent specified in subsection (y)(1) for the 
     year.
       ``(ii) The transition percentage specified in this clause 
     for--
       ``(I) 2014 is 50 percent;
       ``(II) 2015 is 60 percent;
       ``(III) 2016 is 70 percent;
       ``(IV) 2017 is 80 percent;
       ``(V) 2018 is 90 percent; and
       ``(VI) 2019 and each subsequent year is 100 percent.''; and
       (C) by redesignating paragraph (5) (as added by paragraph 
     (1)(A) of this section) as paragraph (3), realigning the left 
     margins to align with paragraph (2), and striking the heading 
     and all that follows through ``a State is'' and inserting ``A 
     State is''.

     SEC. 1202. PAYMENTS TO PRIMARY CARE PHYSICIANS.

       (a) In General.--
       (1) Fee-for-service payments.--Section 1902 of the Social 
     Security Act (42 U.S.C. 1396a), as amended by section 
     2303(a)(2) of the Patient Protection and Affordable Care Act, 
     is amended--
       (A) in subsection (a)(13)--
       (i) by striking ``and'' at the end of subparagraph (A);
       (ii) by adding ``and'' at the end of subparagraph (B); and
       (iii) by adding at the end the following new subparagraph:
       ``(C) payment for primary care services (as defined in 
     subsection (jj)) furnished in 2013 and 2014 by a physician 
     with a primary specialty designation of family medicine, 
     general internal medicine, or pediatric medicine at a rate 
     not less than 100 percent of the payment rate that applies to 
     such services and physician under part B of title XVIII (or, 
     if greater, the payment rate that would be applicable under 
     such part if the conversion factor under section 1848(d) for 
     the year involved were the conversion factor under such 
     section for 2009);''; and
       (B) by adding at the end the following new subsection:
       ``(jj) Primary Care Services Defined.--For purposes of 
     subsection (a)(13)(C), the term `primary care services' 
     means--
       ``(1) evaluation and management services that are procedure 
     codes (for services covered under title XVIII) for services 
     in the category designated Evaluation and Management in the 
     Healthcare Common Procedure Coding System (established by the 
     Secretary under section 1848(c)(5) as of December 31, 2009, 
     and as subsequently modified); and
       ``(2) services related to immunization administration for 
     vaccines and toxoids for which CPT codes 90465, 90466, 90467, 
     90468, 90471, 90472, 90473, or 90474 (as subsequently 
     modified) apply under such System.''.
       (2) Under medicaid managed care plans.--Section 1932(f) of 
     such Act (42 U.S.C. 1396u-2(f)) is amended--
       (A) in the heading, by adding at the end the following: ``; 
     Adequacy of Payment for Primary Care Services''; and
       (B) by inserting before the period at the end the 
     following: ``and, in the case of primary care services 
     described in section 1902(a)(13)(C), consistent with the 
     minimum payment rates specified in such section (regardless 
     of the manner in which such payments are made, including in 
     the form of capitation or partial capitation)''.
       (b) Increase in Payment Using Increased FMAP.--Section 1905 
     of the Social Security Act, as amended by section 1004(b) of 
     this Act and section 10201(c)(6) of the Patient Protection 
     and Affordable Care Act, is amended by adding at the end the 
     following new subsection:
       ``(dd) Increased FMAP for Additional Expenditures for 
     Primary Care Services.--Notwithstanding subsection (b), with 
     respect to the portion of the amounts expended for medical 
     assistance for services described in section 1902(a)(13)(C) 
     furnished on or after January 1, 2013, and before January 1, 
     2015, that is attributable to the amount by which the minimum 
     payment rate required under such section (or, by application, 
     section 1932(f)) exceeds the payment rate applicable to such 
     services under the State plan as of July 1, 2009, the Federal 
     medical assistance percentage for a State that is one of the 
     50 States or the District of Columbia shall be equal to 100 
     percent. The preceding sentence does not prohibit the payment 
     of Federal financial participation based on the Federal 
     medical assistance percentage for amounts in excess of those 
     specified in such sentence.''.

     SEC. 1203. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.

       (a) In General.--Section 1923(f) of the Social Security Act 
     (42 U.S.C. 1396r-4(f)), as amended by sections 2551(a)(4) and 
     10201(e)(1) of the Patient Protection and Affordable Care 
     Act, is amended--
       (1) in paragraph (6)(B)(iii), in the matter preceding 
     subclause (I), by striking ``or paragraph (7)''; and

[[Page 4452]]

       (2) by striking paragraph (7) and inserting the following:
       ``(7) Medicaid dsh reductions.--
       ``(A) Reductions.--
       ``(i) In general.--For each of fiscal years 2014 through 
     2020 the Secretary shall effect the following reductions:

       ``(I) Reduction in dsh allotments.--The Secretary shall 
     reduce DSH allotments to States in the amount specified under 
     the DSH health reform methodology under subparagraph (B) for 
     the State for the fiscal year.
       ``(II) Reductions in payments.--The Secretary shall reduce 
     payments to States under section 1903(a) for each calendar 
     quarter in the fiscal year, in the manner specified in clause 
     (iii), in an amount equal to \1/4\ of the DSH allotment 
     reduction under subclause (I) for the State for the fiscal 
     year.

       ``(ii) Aggregate reductions.--The aggregate reductions in 
     DSH allotments for all States under clause (i)(I) shall be 
     equal to--

       ``(I) $500,000,000 for fiscal year 2014;
       ``(II) $600,000,000 for fiscal year 2015;
       ``(III) $600,000,000 for fiscal year 2016;
       ``(IV) $1,800,000,000 for fiscal year 2017;
       ``(V) $5,000,000,000 for fiscal year 2018;
       ``(VI) $5,600,000,000 for fiscal year 2019; and
       ``(VII) $4,000,000,000 for fiscal year 2020.

     The Secretary shall distribute such aggregate reductions 
     among States in accordance with subparagraph (B).
       ``(iii) Manner of payment reduction.--The amount of the 
     payment reduction under clause (i)(II) for a State for a 
     quarter shall be deemed an overpayment to the State under 
     this title to be disallowed against the State's regular 
     quarterly draw for all spending under section 1903(d)(2). 
     Such a disallowance is not subject to a reconsideration under 
     subsections (d) and (e) of section 1116.
       ``(iv) Definition.--In this paragraph, the term `State' 
     means the 50 States and the District of Columbia.
       ``(B) DSH health reform methodology.--The Secretary shall 
     carry out subparagraph (A) through use of a DSH Health Reform 
     methodology that meets the following requirements:
       ``(i) The methodology imposes the largest percentage 
     reductions on the States that--

       ``(I) have the lowest percentages of uninsured individuals 
     (determined on the basis of data from the Bureau of the 
     Census, audited hospital cost reports, and other information 
     likely to yield accurate data) during the most recent year 
     for which such data are available; or
       ``(II) do not target their DSH payments on--

       ``(aa) hospitals with high volumes of Medicaid inpatients 
     (as defined in subsection (b)(1)(A)); and
       ``(bb) hospitals that have high levels of uncompensated 
     care (excluding bad debt).
       ``(ii) The methodology imposes a smaller percentage 
     reduction on low DSH States described in paragraph (5)(B).
       ``(iii) The methodology takes into account the extent to 
     which the DSH allotment for a State was included in the 
     budget neutrality calculation for a coverage expansion 
     approved under section 1115 as of July 31, 2009.''.
       (b) Extension of DSH Allotment.--Section 1923(f)(6)(A) of 
     the Social Security Act (42 U.S.C. 1396r-4(f)(6)(A)) is 
     amended by adding at the end the following:
       ``(v) Allotment for 2d, 3rd, and 4th quarters of fiscal 
     year 2012 and for fiscal year 2013.--Notwithstanding the 
     table set forth in paragraph (2):

       ``(I) 2d, 3rd, and 4th quarters of fiscal year 2012.--In 
     the case of a State that has a DSH allotment of $0 for the 
     2d, 3rd, and 4th quarters of fiscal year 2012, the DSH 
     allotment shall be $47,200,000 for such quarters.
       ``(II) Fiscal year 2013.--In the case of a State that has a 
     DSH allotment of $0 for fiscal year 2013, the DSH allotment 
     shall be $53,100,000 for such fiscal year.''.

     SEC. 1204. FUNDING FOR THE TERRITORIES.

       (a) In General.--Part III of subtitle D of title I of the 
     Patient Protection and Affordable Care Act, as amended by 
     section 10104(m) of such Act, is amended by inserting after 
     section 1322 the following section:

     ``SEC. 1323. FUNDING FOR THE TERRITORIES.

       ``(a) In General.--A territory that--
       ``(1) elects consistent with subsection (b) to establish an 
     Exchange in accordance with part II of this subtitle and 
     establishes such an Exchange in accordance with such part 
     shall be treated as a State for purposes of such part and 
     shall be entitled to payment from the amount allocated to the 
     territory under subsection (c); or
       ``(2) does not make such election shall be entitled to an 
     increase in the dollar limitation applicable to the territory 
     under subsections (f) and (g) of section 1108 of the Social 
     Security Act (42 U.S.C. 1308) for such period in such amount 
     for such territory and such increase shall not be taken into 
     account in computing any other amount under such subsections.
       ``(b) Terms and Conditions.--An election under subsection 
     (a)(1) shall--
       ``(1) not be effective unless the election is consistent 
     with section 1321 and is received not later than October 1, 
     2013; and''.
       ``(2) be contingent upon entering into an agreement between 
     the territory and the Secretary that requires that--
       ``(A) funds provided under the agreement shall be used only 
     to provide premium and cost-sharing assistance to residents 
     of the territory obtaining health insurance coverage through 
     the Exchange; and
       ``(B) the premium and cost-sharing assistance provided 
     under such agreement shall be structured in such a manner so 
     as to prevent any gap in assistance for individuals between 
     the income level at which medical assistance is available 
     through the territory's Medicaid plan under title XIX of the 
     Social Security Act and the income level at which premium and 
     cost-sharing assistance is available under the agreement.
       ``(c) Appropriation and Allocation.--
       ``(1) Appropriation.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated for purposes of 
     payment pursuant to subsection (a) $1,000,000,000, to be 
     available during the period beginning with 2014 and ending 
     with 2019.
       ``(2) Allocation.--The Secretary shall allocate the amount 
     appropriated under paragraph (1) among the territories for 
     purposes of carrying out this section as follows:
       ``(A) For Puerto Rico, $925,000,000.
       ``(B) For another territory, the portion of $75,000,000 
     specified by the Secretary.''.
       (b) Medicaid Funding.--
       (1) Increase in funding caps.--Section 1108(g) of the 
     Social Security Act (42 U.S.C. 1308(g)), as amended by 
     section 2005(a) of the Patient Protection and Affordable Care 
     Act, is amended--
       (A) in paragraph (2), by inserting ``and section 1323(a)(2) 
     of the Patient Protection and Affordable Care Act'' after 
     ``subject to''; and
       (B) by striking paragraph (5) and inserting the following:
       ``(5) Additional increase.--The Secretary shall increase 
     the amounts otherwise determined under this subsection for 
     Puerto Rico, the Virgin Islands, Guam, the Northern Mariana 
     Islands, and American Samoa (after the application of 
     subsection (f) and the preceding paragraphs of this 
     subsection) for the period beginning July 1, 2011, and ending 
     on September 30, 2019, by such amounts that the total 
     additional payments under title XIX to such territories 
     equals $6,300,000,000 for such period. The Secretary shall 
     increase such amounts in proportion to the amounts applicable 
     to such territories under this subsection and subsection (f) 
     on the date of enactment of this paragraph.''.
       (2) Disregard of payments; increased fmap.--Section 2005 of 
     the Patient Protection and Affordable Care Act is amended--
       (A) by repealing subsection (b) (and the amendments made by 
     that subsection) and section 1108(g)(4) of the Social 
     Security Act shall be applied as if such amendments had never 
     been enacted; and
       (B) in subsection (c)(2), by striking ``January'' and 
     inserting ``July''.

     SEC. 1205. DELAY IN COMMUNITY FIRST CHOICE OPTION.

       Section 1915(k)(1) of the Social Security Act (42 U.S.C. 
     1396n(k)), as added by section 2401 of the Patient Protection 
     and Affordable Care Act, is amended by striking ``October 1, 
     2010'' and inserting ``October 1, 2011''.

     SEC. 1206. DRUG REBATES FOR NEW FORMULATIONS OF EXISTING 
                   DRUGS.

       (a) Treatment of New Formulations.--Subparagraph (C) of 
     section 1927(c)(2) of the Social Security Act (42 U.S.C. 
     1396r-8(c)(2)), as added by section 2501(d) of the Patient 
     Protection and Affordable Care Act, is amended to read as 
     follows:
       ``(C) Treatment of new formulations.--In the case of a drug 
     that is a line extension of a single source drug or an 
     innovator multiple source drug that is an oral solid dosage 
     form, the rebate obligation with respect to such drug under 
     this section shall be the amount computed under this section 
     for such new drug or, if greater, the product of--
       ``(i) the average manufacturer price of the line extension 
     of a single source drug or an innovator multiple source drug 
     that is an oral solid dosage form;
       ``(ii) the highest additional rebate (calculated as a 
     percentage of average manufacturer price) under this section 
     for any strength of the original single source drug or 
     innovator multiple source drug; and
       ``(iii) the total number of units of each dosage form and 
     strength of the line extension product paid for under the 
     State plan in the rebate period (as reported by the State).
     In this subparagraph, the term `line extension' means, with 
     respect to a drug, a new formulation of the drug, such as an 
     extended release formulation.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect as if included in the enactment of the 
     Patient Protection and Affordable Care Act.

              Subtitle D--Reducing Fraud, Waste, and Abuse

     SEC. 1301. COMMUNITY MENTAL HEALTH CENTERS.

       (a) In General.--Section 1861(ff)(3)(B) of the Social 
     Security Act (42 U.S.C. 1395x(ff)(3)(B)) is amended--
       (1) in clause (ii), by striking ``and'' at the end;
       (2) by redesignating clause (iii) as clause (iv); and
       (3) by inserting after clause (ii) the following:
       ``(iii) provides at least 40 percent of its services to 
     individuals who are not eligible for benefits under this 
     title; and''.
       (b) Restriction.--Section 1861(ff)(3)(A) of such Act (42 
     U.S.C. 1395x(ff)(3)(A)) is amended by inserting ``other than 
     in an individual's home or in an inpatient or residential 
     setting'' before the period.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after the 
     first day of the first calendar quarter that begins at least 
     12 months after the date of the enactment of this Act.

     SEC. 1302. MEDICARE PREPAYMENT MEDICAL REVIEW LIMITATIONS .

       Section 1874A(h) of the Social Security Act (42 U.S.C. 
     1395w-3a(h)) is repealed.

[[Page 4453]]



     SEC. 1303. FUNDING TO FIGHT FRAUD, WASTE, AND ABUSE.

       (a) Funding to Fight Fraud, Waste, and Abuse.--
       (1) In general.--Section 1817(k) of the Social Security Act 
     (42 U.S.C. 1395i(k)), as amended by section 6402(i) of the 
     Patient Protection and Affordable Care Act, is further 
     amended--
       (A) by adding at the end the following new paragraph:
       ``(8) Additional funding.--
       ``(A) In general.--In addition to the funds otherwise 
     appropriated to the Account from the Trust Fund under 
     paragraphs (3)(C) and (4)(A) and for purposes described in 
     paragraphs (3)(C) and (4)(A), there are hereby appropriated 
     to such Account from such Trust Fund the following additional 
     amounts:
       ``(i) For fiscal year 2011, $95,000,000.
       ``(ii) For fiscal year 2012, $55,000,000.
       ``(iii) For each of fiscal years 2013 and 2014, 
     $30,000,000.
       ``(iv) For each of fiscal years 2015 and 2016, $20,000,000.
       ``(B) Allocation.--The funds appropriated under this 
     paragraph shall be allocated in the same proportion as the 
     total funding appropriated with respect to paragraphs (3)(A) 
     and (4)(A) was allocated with respect to fiscal year 2010, 
     and shall be available without further appropriation until 
     expended.''; and
       (B) in paragraph (4)(A), by inserting ``for activities 
     described in paragraph (3)(C) and'' after ``necessary''.
       (b) Medicaid Integrity Program.--Section 1936(e)(1) of such 
     Act (42 U.S.C. 1396-u6(e)(1)) is amended--
       (1) in subparagraph (B), by striking at the end ``and'';
       (2) in subparagraph (C)--
       (A) by striking ``for each fiscal year thereafter'' and 
     inserting ``for each of fiscal years 2009 and 2010''; and
       (B) by striking the period and inserting ``; and''; and
       (3) by adding at the end the following new subparagraph:
       ``(D) for each fiscal year after fiscal year 2010, the 
     amount appropriated under this paragraph for the previous 
     fiscal year, increased by the percentage increase in the 
     consumer price index for all urban consumers (all items; 
     United States city average) over the previous year.''.

     SEC. 1304. 90-DAY PERIOD OF ENHANCED OVERSIGHT FOR INITIAL 
                   CLAIMS OF DME SUPPLIERS.

       Section 1866(j), as amended by section 6401 of the Patient 
     Protection and Affordable Care Act, is further amended--
       (1) by redesignating paragraphs (4) through (7) as 
     paragraphs (5) through (8), respectively; and
       (2) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) 90-day period of enhanced oversight for initial 
     claims of dme suppliers.--For periods beginning after January 
     1, 2011, if the Secretary determines  that there is a 
     significant risk of fraudulent activity among suppliers of 
     durable medical equipment, in the case of a supplier of 
     durable medical equipment who is within a category or 
     geographic area under title XVIII identified pursuant to such 
     determination and who is initially enrolling under such 
     title, the Secretary shall, notwithstanding sections 1816(c), 
     1842(c), and 1869(a)(2), withhold payment under such title 
     with respect to durable medical equipment furnished by such 
     supplier during the 90-day period beginning on the date of 
     the first submission of a claim under such title for durable 
     medical equipment furnished by such supplier.''.

               Subtitle E--Provisions Relating to Revenue

     SEC. 1401. HIGH-COST PLAN EXCISE TAX.

       (a) In General.--Section 4980I of the Internal Revenue Code 
     of 1986, as added by section 9001 of the Patient Protection 
     and Affordable Care Act and amended by section 10901 of such 
     Act, is amended--
       (1) in subsection (b)(3)(B)--
       (A) by striking ``The annual'' and inserting the following:
       ``(i) In general.--Except as provided in clause (ii), the 
     annual'', and
       (B) by adding at the end the following new clause:
       ``(ii) Multiemployer plan coverage.--Any coverage provided 
     under a multiemployer plan (as defined in section 414(f)) 
     shall be treated as coverage other than self-only 
     coverage.'',
       (2) in subsection (b)(3)(C)--
       (A) by striking ``Except as provided in subparagraph (D)--
     ''
       (B) in clause (i)--
       (i) by striking ``2013'' each place it appears in the 
     heading and the text and inserting ``2018'',
       (ii) by striking ``$8,500'' in subclause (I) and inserting 
     ``$10,200 multiplied by the health cost adjustment percentage 
     (determined by only taking into account self-only 
     coverage)'', and
       (iii) by striking ``$23,000'' in subclause (II) and 
     inserting ``$27,500 multiplied by the health cost adjustment 
     percentage (determined by only taking into account coverage 
     other than self-only coverage)'',
       (C) by redesignating clauses (ii) and (iii) as clauses (iv) 
     and (v), respectively, and by inserting after clause (i) the 
     following new clauses:
       ``(ii) Health cost adjustment percentage.--For purposes of 
     clause (i), the health cost adjustment percentage is equal to 
     100 percent plus the excess (if any) of--

       ``(I) the percentage by which the per employee cost for 
     providing coverage under the Blue Cross/Blue Shield standard 
     benefit option under the Federal Employees Health Benefits 
     Plan for plan year 2018 (determined by using the benefit 
     package for such coverage in 2010) exceeds such cost for plan 
     year 2010, over
       ``(II) 55 percent.

       ``(iii) Age and gender adjustment.--

       ``(I) In general.--The amount determined under subclause 
     (I) or (II) of clause (i), whichever is applicable, for any 
     taxable period shall be increased by the amount determined 
     under subclause (II).

       ``(II) Amount determined.--The amount determined under this 
     subclause is an amount equal to the excess (if any) of--

       ``(aa) the premium cost of the Blue Cross/Blue Shield 
     standard benefit option under the Federal Employees Health 
     Benefits Plan for the type of coverage provided such 
     individual in such taxable period if priced for the age and 
     gender characteristics of all employees of the individual's 
     employer, over
       ``(bb) that premium cost for the provision of such coverage 
     under such option in such taxable period if priced for the 
     age and gender characteristics of the national workforce.''.
       (D) in clause (iv), as redesignated by subparagraph (C)--
       (i) by inserting ``covered by the plan'' after ``whose 
     employees'', and
       (ii) by striking subclauses (I) and (II) and inserting the 
     following:

       ``(I) the dollar amount in clause (i)(I) shall be increased 
     by $1,650, and
       ``(II) the dollar amount in clause (i)(II) shall be 
     increased by $3,450,'', and

       (E) in clause (v), as redesignated by subparagraph (C)--
       (i) by striking ``2013'' and inserting ``2018'',
       (ii) by striking ``clauses (i) and (ii)'' and inserting 
     ``clauses (i) (after the application of clause (ii)) and 
     (iv)'', and
       (iii) by inserting ``in the case of determinations for 
     calendar years beginning before 2020'' after ``1 percentage 
     point'' in subclause (II) thereof,
       (3) by striking subparagraph (D) of subsection (b)(3),
       (4) in subsection (d)(1)(B), by redesignating clause (ii) 
     as clause (iii) and by inserting after clause (i) the 
     following new clause:
       ``(ii) any coverage under a separate policy, certificate, 
     or contract of insurance which provides benefits 
     substantially all of which are for treatment of the mouth 
     (including any organ or structure within the mouth) or for 
     treatment of the eye, or'', and
       (5) in subsection (d), by adding at the end the following 
     new paragraph:
       ``(3) Employee.--The term `employee' includes any former 
     employee, surviving spouse, or other primary insured 
     individual.''.
       (b) Effective Dates.--
       (1) Section 9001(c) of the Patient Protection and 
     Affordable Care Act is amended by striking ``2012'' and 
     inserting ``2017''.
       (2) Section 10901(c) of the Patient Protection and 
     Affordable Care Act is amended by striking ``2012'' and 
     inserting ``2017''.

     SEC. 1402. UNEARNED INCOME MEDICARE CONTRIBUTION.

       (a) Investment Income.--
       (1) In general.--Subtitle A of the Internal Revenue Code of 
     1986 is amended by inserting after chapter 2 the following 
     new chapter:

          ``CHAPTER 2A--UNEARNED INCOME MEDICARE CONTRIBUTION

``Sec. 1411. Imposition of tax.

     ``SEC. 1411. IMPOSITION OF TAX.

       ``(a) In General.--Except as provided in subsection (e)--
       ``(1) Application to individuals.--In the case of an 
     individual, there is hereby imposed (in addition to any other 
     tax imposed by this subtitle) for each taxable year a tax 
     equal to 3.8 percent of the lesser of--
       ``(A) net investment income for such taxable year, or
       ``(B) the excess (if any) of--
       ``(i) the modified adjusted gross income for such taxable 
     year, over
       ``(ii) the threshold amount.
       ``(2) Application to estates and trusts.--In the case of an 
     estate or trust, there is hereby imposed (in addition to any 
     other tax imposed by this subtitle) for each taxable year a 
     tax of 3.8 percent of the lesser of--
       ``(A) the undistributed net investment income for such 
     taxable year, or
       ``(B) the excess (if any) of--
       ``(i) the adjusted gross income (as defined in section 
     67(e)) for such taxable year, over
       ``(ii) the dollar amount at which the highest tax bracket 
     in section 1(e) begins for such taxable year.
       ``(b) Threshold Amount.--For purposes of this chapter, the 
     term `threshold amount' means--
       ``(1) in the case of a taxpayer making a joint return under 
     section 6013 or a surviving spouse (as defined in section 
     2(a)), $250,000,
       ``(2) in the case of a married taxpayer (as defined in 
     section 7703) filing a separate return, \1/2\ of the dollar 
     amount determined under paragraph (1), and
       ``(3) in any other case, $200,000.
       ``(c) Net Investment Income.--For purposes of this 
     chapter--
       ``(1) In general.--The term `net investment income' means 
     the excess (if any) of--
       ``(A) the sum of--
       ``(i) gross income from interest, dividends, annuities, 
     royalties, and rents, other than such income which is derived 
     in the ordinary course of a trade or business not described 
     in paragraph (2),
       ``(ii) other gross income derived from a trade or business 
     described in paragraph (2), and
       ``(iii) net gain (to the extent taken into account in 
     computing taxable income) attributable

[[Page 4454]]

     to the disposition of property other than property held in a 
     trade or business not described in paragraph (2), over
       ``(B) the deductions allowed by this subtitle which are 
     properly allocable to such gross income or net gain.
       ``(2) Trades and businesses to which tax applies.--A trade 
     or business is described in this paragraph if such trade or 
     business is--
       ``(A) a passive activity (within the meaning of section 
     469) with respect to the taxpayer, or
       ``(B) a trade or business of trading in financial 
     instruments or commodities (as defined in section 475(e)(2)).
       ``(3) Income on investment of working capital subject to 
     tax.--A rule similar to the rule of section 469(e)(1)(B) 
     shall apply for purposes of this subsection.
       ``(4) Exception for certain active interests in 
     partnerships and s corporations.--In the case of a 
     disposition of an interest in a partnership or S 
     corporation--
       ``(A) gain from such disposition shall be taken into 
     account under clause (iii) of paragraph (1)(A) only to the 
     extent of the net gain which would be so taken into account 
     by the transferor if all property of the partnership or S 
     corporation were sold for fair market value immediately 
     before the disposition of such interest, and
       ``(B) a rule similar to the rule of subparagraph (A) shall 
     apply to a loss from such disposition.
       ``(5) Exception for distributions from qualified plans.--
     The term `net investment income' shall not include any 
     distribution from a plan or arrangement described in section 
     401(a), 403(a), 403(b), 408, 408A, or 457(b).
       ``(6) Special rule.--Net investment income shall not 
     include any item taken into account in determining self-
     employment income for such taxable year on which a tax is 
     imposed by section 1401(b).
       ``(d) Modified Adjusted Gross Income.--For purposes of this 
     chapter, the term `modified adjusted gross income' means 
     adjusted gross income increased by the excess of--
       ``(1) the amount excluded from gross income under section 
     911(a)(1), over
       ``(2) the amount of any deductions (taken into account in 
     computing adjusted gross income) or exclusions disallowed 
     under section 911(d)(6) with respect to the amounts described 
     in paragraph (1).
       ``(e) Nonapplication of Section.--This section shall not 
     apply to--
       ``(1) a nonresident alien, or
       ``(2) a trust all of the unexpired interests in which are 
     devoted to one or more of the purposes described in section 
     170(c)(2)(B).''.
       (2) Estimated taxes.--Section 6654 of the Internal Revenue 
     Code of 1986 is amended--
       (A) in subsection (a), by striking ``and the tax under 
     chapter 2'' and inserting ``the tax under chapter 2, and the 
     tax under chapter 2A'', and
       (B) in subsection (f)--
       (i) by striking ``minus'' at the end of paragraph (2) and 
     inserting ``plus'', and
       (ii) by redesignating paragraph (3) as paragraph (4) and 
     inserting after paragraph (2) the following new paragraph:
       ``(3) the taxes imposed by chapter 2A, minus''.
       (3) Clerical amendment.--The table of chapters for subtitle 
     A of chapter 1 of the Internal Revenue Code of 1986 is 
     amended by inserting after the item relating to chapter 2 the 
     following new item:

         ``Chapter 2A--Unearned Income Medicare Contribution''.

       (4) Effective dates.--The amendments made by this 
     subsection shall apply to taxable years beginning after 
     December 31, 2012.
       (b) Earned Income.--
       (1) Threshold.--
       (A) FICA.--Paragraph (2) of section 3101(b) of the Internal 
     Revenue Code of 1986, as added by section 9015 of the Patient 
     Protection and Affordable Care Act and amended by section 
     10906 of such Act, is amended by striking ``and'' at the end 
     of subparagraph (A), by redesignating subparagraph (B) as 
     subparagraph (C), and by inserting after subparagraph (A) the 
     following new subparagraph:
       ``(B) in the case of a married taxpayer (as defined in 
     section 7703) filing a separate return, \1/2\ of the dollar 
     amount determined under subparagraph (A), and''.
       (B) SECA.--Section 1401(b)(2) of the Internal Revenue Code 
     of 1986, as added by section 9015 of the Patient Protection 
     and Affordable Care Act and amended by section 10906 of such 
     Act, is amended--
       (i) in subparagraph (A), by striking ``and'' at the end of 
     clause (i), by redesignating clause (ii) as clause (iii), and 
     by inserting after clause (i) the following new clause:
       ``(ii) in the case of a married taxpayer (as defined in 
     section 7703) filing a separate return, \1/2\ of the dollar 
     amount determined under clause (i), and'', and
       (ii) in subparagraph (B), by striking ``under clauses (i) 
     and (ii)'' and inserting ``under clause (i), (ii), or (iii) 
     (whichever is applicable)''.
       (2) Estimated taxes.--Section 6654 of the Internal Revenue 
     Code of 1986 is amended by redesignating subsection (m) as 
     subsection (n) and by inserting after subsection (l) the 
     following new subsection:
       ``(m) Special Rule for Medicare Tax.--For purposes of this 
     section, the tax imposed under section 3101(b)(2) (to the 
     extent not withheld) shall be treated as a tax imposed under 
     chapter 2.''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply with respect to remuneration received, and 
     taxable years beginning after, December 31, 2012.

     SEC. 1403. DELAY OF LIMITATION ON HEALTH FLEXIBLE SPENDING 
                   ARRANGEMENTS UNDER CAFETERIA PLANS.

       (a) In General.--Section 10902(b) of the Patient Protection 
     and Affordable Care Act is amended by striking ``December 31, 
     2010'' and inserting ``December 31, 2012''.
       (b) Inflation Adjustment.--Paragraph (2) of section 125(i) 
     of the Internal Revenue Code of 1986, as added by section 
     9005 of the Patient Protection and Affordable Care Act and 
     amended by section 10902 of such Act, is amended--
       (1) in the matter preceding subparagraph (A), by striking 
     ``December 31, 2011'' and inserting ``December 31, 2013'', 
     and
       (2) in subparagraph (B), by striking ``2010'' and inserting 
     ``2012''.

     SEC. 1404. BRAND NAME PHARMACEUTICALS.

       (a) In General.--Section 9008 of the Patient Protection and 
     Affordable Care Act is amended--
       (1) in subsection (a)(1), by striking ``2009'' and 
     inserting ``2010'',
       (2) in subsection (b)--
       (A) by striking ``$2,300,000,000'' in paragraph (1) and 
     inserting ``the applicable amount'', and
       (B) by adding at the end the following new paragraph:
       ``(4) Applicable amount.--For purposes of paragraph (1), 
     the applicable amount shall be determined in accordance with 
     the following table:


``Calendar year                             Applicable amount
  2011....................................  $2,500,000,000
  2012....................................  $2,800,000,000
  2013....................................  $2,800,000,000
  2014....................................  $3,000,000,000
  2015....................................  $3,000,000,000
  2016....................................  $3,000,000,000
  2017....................................  $4,000,000,000.
  2018....................................  $4,100,000,000
  2019 and thereafter.....................  $2,800,000,000.'',
 

       (3) in subsection (d), by adding at the end the following 
     new paragraph:
       ``(3) Joint and several liability.--If more than one person 
     is liable for payment of the fee under subsection (a) with 
     respect to a single covered entity by reason of the 
     application of paragraph (2), all such persons shall be 
     jointly and severally liable for payment of such fee.'', and
       (4) by striking subsection (j) and inserting the following 
     new subsection:
       ``(j) Effective Date.--This section shall apply to calendar 
     years beginning after December 31, 2010.''.
       (b) Effective Date.--The amendments made by this section 
     shall take effect as if included in section 9008 of the 
     Patient Protection and Affordable Care Act.

     SEC. 1405. EXCISE TAX ON MEDICAL DEVICE MANUFACTURERS.

       (a) In General.--Chapter 32 of the Internal Revenue Code of 
     1986 is amended--
       (1) by inserting after subchapter D the following new 
     subchapter:

                    ``Subchapter E--Medical Devices

``Sec. 4191. Medical devices.

     ``SEC. 4191. MEDICAL DEVICES.

       ``(a) In General.--There is hereby imposed on the sale of 
     any taxable medical device by the manufacturer, producer, or 
     importer a tax equal to 2.3 percent of the price for which so 
     sold.
       ``(b) Taxable Medical Device.--For purposes of this 
     section--
       ``(1) In general.--The term `taxable medical device' means 
     any device (as defined in section 201(h) of the Federal Food, 
     Drug, and Cosmetic Act) intended for humans.
       ``(2) Exemptions.--Such term shall not include--
       ``(A) eyeglasses,
       ``(B) contact lenses,
       ``(C) hearing aids, and
       ``(D) any other medical device determined by the Secretary 
     to be of a type which is generally purchased by the general 
     public at retail for individual use.'', and
       (2) by inserting after the item relating to subchapter D in 
     the table of subchapters for such chapter the following new 
     item:

                  ``subchapter e. medical devices.''.

       (b) Certain Exemptions Not to Apply.--
       (1) Section 4221(a) of the Internal Revenue Code of 1986 is 
     amended by adding at the end the following new sentence: ``In 
     the case of the tax imposed by section 4191, paragraphs (3), 
     (4), (5), and (6) shall not apply.''.
       (2) Section 6416(b)(2) of such Code is amended by adding at 
     the end the following: ``In the case of the tax imposed by 
     section 4191, subparagraphs (B), (C), (D), and (E) shall not 
     apply.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to sales after December 31, 2012.
       (d) Repeal of Section 9009 of the Patient Protection and 
     Affordable Care Act.--Section 9009 of the Patient Protection 
     and Affordable Care Act, as amended by section 10904 of such 
     Act, is repealed effective as of the date of enactment of 
     that Act.

     SEC. 1406. HEALTH INSURANCE PROVIDERS.

       (a) In General.--Section 9010 of the Patient Protection and 
     Affordable Care Act, as amended by section 10905 of such Act, 
     is amended--
       (1) in subsection (a)(1), by striking ``2010'' and 
     inserting ``2013'',
       (2) in subsection (b)(2)--
       (A) by striking ``For purposes of paragraph (1), the net 
     premiums'' and inserting ``For purposes of paragraph (1)--
       ``(A) In general.--The net premiums'', and
       (B) by adding at the end the following subparagraph:

[[Page 4455]]

       ``(B) Partial exclusion for certain exempt activities.--
     After the application of subparagraph (A), only 50 percent of 
     the remaining net premiums written with respect to health 
     insurance for any United States health risk that are 
     attributable to the activities (other than activities of an 
     unrelated trade or business as defined in section 513 of the 
     Internal Revenue Code of 1986) of any covered entity 
     qualifying under paragraph (3), (4), (26), or (29) of section 
     501(c) of such Code and exempt from tax under section 501(a) 
     of such Code shall be taken into account.'',
       (3) in subsection (c)--
       (A) by inserting ``during the calendar year in which the 
     fee under this section is due'' in paragraph (1) after 
     ``risk'',
       (B) in paragraph (2), by striking subparagraphs (C), (D), 
     and (E) and inserting the following new subparagraphs:
       ``(C) any entity--
       ``(i) which is incorporated as a nonprofit corporation 
     under a State law,
       ``(ii) no part of the net earnings of which inures to the 
     benefit of any private shareholder or individual, no 
     substantial part of the activities of which is carrying on 
     propaganda, or otherwise attempting, to influence legislation 
     (except as otherwise provided in section 501(h) of the 
     Internal Revenue Code of 1986), and which does not 
     participate in, or intervene in (including the publishing or 
     distributing of statements), any political campaign on behalf 
     of (or in opposition to) any candidate for public office, and
       ``(iii) more than 80 percent of the gross revenues of which 
     is received from government programs that target low-income, 
     elderly, or disabled populations under titles XVIII, XIX, and 
     XXI of the Social Security Act, and
       ``(D) any entity which is described in section 501(c)(9) of 
     such Code and which is established by an entity (other than 
     by an employer or employers) for purposes of providing health 
     care benefits.'',
       (C) in paragraph (3)(A), by striking ``subparagraph 
     (C)(i)(I), (D)(i)(I), or (E)(i)'' and inserting 
     ``subparagraph (C) or (D)'', and
       (D) by adding at the end the following new paragraph:
       ``(4) Joint and several liability.--If more than one person 
     is liable for payment of the fee under subsection (a) with 
     respect to a single covered entity by reason of the 
     application of paragraph (3), all such persons shall be 
     jointly and severally liable for payment of such fee.'',
       (4) by striking subsection (e) and inserting the following:
       ``(e) Applicable Amount.--For purposes of subsection 
     (b)(1)--
       ``(1) Years before 2019.--In the case of calendar years 
     beginning before 2019, the applicable amount shall be 
     determined in accordance with the following table:


``Calendar year                             Applicable amount
  2014....................................  $8,000,000,000
  2015....................................  $11,300,000,000
  2016....................................  $11,300,000,000
  2017....................................  $13,900,000,000
  2018....................................  $14,300,000,000.
 

       ``(2) Years after 2018.--In the case of any calendar year 
     beginning after 2018, the applicable amount shall be the 
     applicable amount for the preceding calendar year increased 
     by the rate of premium growth (within the meaning of section 
     36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986) for 
     such preceding calendar year.'',
       (5) in subsection (g), by adding at the end the following 
     new paragraphs:
       ``(3) Accuracy-related penalty.--
       ``(A) In general.--In the case of any understatement of a 
     covered entity's net premiums written with respect to health 
     insurance for any United States health risk for any calendar 
     year, there shall be paid by the covered entity making such 
     understatement, an amount equal to the excess of--
       ``(i) the amount of the covered entity's fee under this 
     section for the calendar year the Secretary determines should 
     have been paid in the absence of any such understatement, 
     over
       ``(ii) the amount of such fee the Secretary determined 
     based on such understatement.
       ``(B) Understatement.--For purposes of this paragraph, an 
     understatement of a covered entity's net premiums written 
     with respect to health insurance for any United States health 
     risk for any calendar year is the difference between the 
     amount of such net premiums written as reported on the return 
     filed by the covered entity under paragraph (1) and the 
     amount of such net premiums written that should have been 
     reported on such return.
       ``(C) Treatment of penalty.--The penalty imposed under 
     subparagraph (A) shall be subject to the provisions of 
     subtitle F of the Internal Revenue Code of 1986 that apply to 
     assessable penalties imposed under chapter 68 of such Code.
       ``(4) Treatment of information.--Section 6103 of the 
     Internal Revenue Code of 1986 shall not apply to any 
     information reported under this subsection.'', and
       (6) by striking subsection (j) and inserting the following 
     new subsection:
       ``(j) Effective Date.--This section shall apply to calendar 
     years beginning after December 31, 2013.''.
       (b) Effective Date.--The amendments made by this section 
     shall take effect as if included in section 9010 of the 
     Patient Protection and Affordable Care Act.

     SEC. 1407. DELAY OF ELIMINATION OF DEDUCTION FOR EXPENSES 
                   ALLOCABLE TO MEDICARE PART D SUBSIDY.

       Section 9012(b) of the Patient Protection and Affordable 
     Care Act is amended by striking ``2010'' and inserting 
     ``2012''.

     SEC. 1408. ELIMINATION OF UNINTENDED APPLICATION OF 
                   CELLULOSIC BIOFUEL PRODUCER CREDIT.

       (a) In General.--Section 40(b)(6)(E) of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new clause:
       ``(iii) Exclusion of unprocessed fuels.--The term 
     `cellulosic biofuel' shall not include any fuel if--

       ``(I) more than 4 percent of such fuel (determined by 
     weight) is any combination of water and sediment, or
       ``(II) the ash content of such fuel is more than 1 percent 
     (determined by weight).''.

       (b) Effective Date.--The amendment made by this section 
     shall apply to fuels sold or used on or after January 1, 
     2010.

     SEC. 1409. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE AND 
                   PENALTIES.

       (a) In General.--Section 7701 of the Internal Revenue Code 
     of 1986 is amended by redesignating subsection (o) as 
     subsection (p) and by inserting after subsection (n) the 
     following new subsection:
       ``(o) Clarification of Economic Substance Doctrine.--
       ``(1) Application of doctrine.--In the case of any 
     transaction to which the economic substance doctrine is 
     relevant, such transaction shall be treated as having 
     economic substance only if--
       ``(A) the transaction changes in a meaningful way (apart 
     from Federal income tax effects) the taxpayer's economic 
     position, and
       ``(B) the taxpayer has a substantial purpose (apart from 
     Federal income tax effects) for entering into such 
     transaction.
       ``(2) Special rule where taxpayer relies on profit 
     potential.--
       ``(A) In general.--The potential for profit of a 
     transaction shall be taken into account in determining 
     whether the requirements of subparagraphs (A) and (B) of 
     paragraph (1) are met with respect to the transaction only if 
     the present value of the reasonably expected pre-tax profit 
     from the transaction is substantial in relation to the 
     present value of the expected net tax benefits that would be 
     allowed if the transaction were respected.
       ``(B) Treatment of fees and foreign taxes.--Fees and other 
     transaction expenses shall be taken into account as expenses 
     in determining pre-tax profit under subparagraph (A). The 
     Secretary shall issue regulations requiring foreign taxes to 
     be treated as expenses in determining pre-tax profit in 
     appropriate cases.
       ``(3) State and local tax benefits.--For purposes of 
     paragraph (1), any State or local income tax effect which is 
     related to a Federal income tax effect shall be treated in 
     the same manner as a Federal income tax effect.
       ``(4) Financial accounting benefits.--For purposes of 
     paragraph (1)(B), achieving a financial accounting benefit 
     shall not be taken into account as a purpose for entering 
     into a transaction if the origin of such financial accounting 
     benefit is a reduction of Federal income tax.
       ``(5) Definitions and special rules.--For purposes of this 
     subsection--
       ``(A) Economic substance doctrine.--The term `economic 
     substance doctrine' means the common law doctrine under which 
     tax benefits under subtitle A with respect to a transaction 
     are not allowable if the transaction does not have economic 
     substance or lacks a business purpose.
       ``(B) Exception for personal transactions of individuals.--
     In the case of an individual, paragraph (1) shall apply only 
     to transactions entered into in connection with a trade or 
     business or an activity engaged in for the production of 
     income.
       ``(C) Determination of application of doctrine not 
     affected.--The determination of whether the economic 
     substance doctrine is relevant to a transaction shall be made 
     in the same manner as if this subsection had never been 
     enacted.
       ``(D) Transaction.--The term `transaction' includes a 
     series of transactions.''.
       (b) Penalty for Underpayments Attributable to Transactions 
     Lacking Economic Substance.--
       (1) In general.--Subsection (b) of section 6662 is amended 
     by inserting after paragraph (5) the following new paragraph:
       ``(6) Any disallowance of claimed tax benefits by reason of 
     a transaction lacking economic substance (within the meaning 
     of section 7701(o)) or failing to meet the requirements of 
     any similar rule of law.''.
       (2) Increased penalty for nondisclosed transactions.--
     Section 6662 is amended by adding at the end the following 
     new subsection:
       ``(i) Increase in Penalty in Case of Nondisclosed 
     Noneconomic Substance Transactions.--
       ``(1) In general.--In the case of any portion of an 
     underpayment which is attributable to one or more 
     nondisclosed noneconomic substance transactions, subsection 
     (a) shall be applied with respect to such portion by 
     substituting `40 percent' for `20 percent'.
       ``(2) Nondisclosed noneconomic substance transactions.--For 
     purposes of this subsection, the term `nondisclosed 
     noneconomic substance transaction' means any portion of a 
     transaction described in subsection (b)(6) with respect to 
     which the relevant facts affecting the tax treatment are not 
     adequately disclosed in the return nor in a statement 
     attached to the return.
       ``(3) Special rule for amended returns.--In no event shall 
     any amendment or supplement

[[Page 4456]]

     to a return of tax be taken into account for purposes of this 
     subsection if the amendment or supplement is filed after the 
     earlier of the date the taxpayer is first contacted by the 
     Secretary regarding the examination of the return or such 
     other date as is specified by the Secretary.''.
       (3) Conforming amendment.--Subparagraph (B) of section 
     6662A(e)(2) is amended--
       (A) by striking ``section 6662(h)'' and inserting 
     ``subsections (h) or (i) of section 6662''; and
       (B) by striking ``gross valuation misstatement penalty'' in 
     the heading and inserting ``certain increased underpayment 
     penalties''.
       (c) Reasonable Cause Exception Not Applicable to 
     Noneconomic Substance Transactions.--
       (1) Reasonable cause exception for underpayments.--
     Subsection (c) of section 6664 is amended--
       (A) by redesignating paragraphs (2) and (3) as paragraphs 
     (3) and (4), respectively;
       (B) by striking ``paragraph (2)'' in paragraph (4)(A), as 
     so redesignated, and inserting ``paragraph (3)''; and
       (C) by inserting after paragraph (1) the following new 
     paragraph:
       ``(2) Exception.--Paragraph (1) shall not apply to any 
     portion of an underpayment which is attributable to one or 
     more transactions described in section 6662(b)(6).''.
       (2) Reasonable cause exception for reportable transaction 
     understatements.--Subsection (d) of section 6664 is amended--
       (A) by redesignating paragraphs (2) and (3) as paragraphs 
     (3) and (4), respectively;
       (B) by striking ``paragraph (2)(C)'' in paragraph (4), as 
     so redesignated, and inserting ``paragraph (3)(C)''; and
       (C) by inserting after paragraph (1) the following new 
     paragraph:
       ``(2) Exception.--Paragraph (1) shall not apply to any 
     portion of a reportable transaction understatement which is 
     attributable to one or more transactions described in section 
     6662(b)(6).''.
       (d) Application of Penalty for Erroneous Claim for Refund 
     or Credit to Noneconomic Substance Transactions.--Section 
     6676 is amended by redesignating subsection (c) as subsection 
     (d) and inserting after subsection (b) the following new 
     subsection:
       ``(c) Noneconomic Substance Transactions Treated as Lacking 
     Reasonable Basis.--For purposes of this section, any 
     excessive amount which is attributable to any transaction 
     described in section 6662(b)(6) shall not be treated as 
     having a reasonable basis.''.
       (e) Effective Date.--
       (1) In general.--Except as otherwise provided in this 
     subsection, the amendments made by this section shall apply 
     to transactions entered into after the date of the enactment 
     of this Act.
       (2) Underpayments.--The amendments made by subsections (b) 
     and (c)(1) shall apply to underpayments attributable to 
     transactions entered into after the date of the enactment of 
     this Act.
       (3) Understatements.--The amendments made by subsection 
     (c)(2) shall apply to understatements attributable to 
     transactions entered into after the date of the enactment of 
     this Act.
       (4) Refunds and credits.--The amendment made by subsection 
     (d) shall apply to refunds and credits attributable to 
     transactions entered into after the date of the enactment of 
     this Act.

     SEC. 1410. TIME FOR PAYMENT OF CORPORATE ESTIMATED TAXES.

       The percentage under paragraph (1) of section 202(b) of the 
     Corporate Estimated Tax Shift Act of 2009 in effect on the 
     date of the enactment of this Act is increased by 15.75 
     percentage points.

                      Subtitle F--Other Provisions

     SEC. 1501. COMMUNITY COLLEGE AND CAREER TRAINING GRANT 
                   PROGRAM.

       Section 279(b) of the Trade Act of 1974 (19 U.S.C. 
     2372a(b)) is amended by striking ``Supplement'' and all that 
     follows through ``Funds'' and inserting ``There are'' and by 
     striking ``pursuant'' and all that follows and inserting 
     ``$500,000,000 for each of fiscal years 2011, 2012, 2013, and 
     2014 to carry out this subchapter, except that the 
     limitations contained in section 278(a)(2) shall not apply to 
     such funds and each State shall receive not less than 0.5 
     percent of the amount appropriated pursuant to this 
     subsection for each such fiscal year.''.

                     TITLE II--EDUCATION AND HEALTH

                         Subtitle A--Education

     SEC. 2001. SHORT TITLE; REFERENCES.

       (a) Short Title.--This subtitle may be cited as the ``SAFRA 
     Act''.
       (b) References.--Except as otherwise expressly provided, 
     whenever in this subtitle an amendment or repeal is expressed 
     in terms of an amendment to, or repeal of, a section or other 
     provision, the reference shall be considered to be made to a 
     section or other provision of the Higher Education Act of 
     1965 (20 U.S.C. 1001 et seq.).

               PART I--INVESTING IN STUDENTS AND FAMILIES

     SEC. 2101. FEDERAL PELL GRANTS.

       (a) Amount of Grants.--Section 401(b) (20 U.S.C. 1070a(b)) 
     is amended--
       (1) by amending paragraph (2)(A) to read as follows:
       ``(A) The amount of the Federal Pell Grant for a student 
     eligible under this part shall be--
       ``(i) the maximum Federal Pell Grant, as specified in the 
     last enacted appropriation Act applicable to that award year, 
     plus
       ``(ii) the amount of the increase calculated under 
     paragraph (8)(B) for that year, less
       ``(iii) an amount equal to the amount determined to be the 
     expected family contribution with respect to that student for 
     that year.''; and
       (2) in paragraph (8)--
       (A) in subparagraph (A)--
       (i) in the matter preceding clause (i), by striking ``, to 
     carry out subparagraph (B) of this paragraph''; and
       (ii) by striking clauses (iii) through (x) and inserting 
     the following:
       ``(iii) to carry out subparagraph (B) of this paragraph, 
     such sums as may be necessary for fiscal year 2010 and each 
     subsequent fiscal year to provide the amount of increase of 
     the maximum Federal Pell Grant required by clauses (ii) and 
     (iii) of subparagraph (B); and
       ``(iv) to carry out this section, $13,500,000,000 for 
     fiscal year 2011.'';
       (B) in subparagraph (B)--
       (i) in the matter preceding clause (i), by striking 
     ``subparagraph (A)'' and inserting ``clauses (i) through 
     (iii) of subparagraph (A)'';
       (ii) in clause (ii), by striking ``and 2011-2012'' and 
     inserting ``, 2011 092012, and 2012-2013''; and
       (iii) by striking clause (iii) and inserting the following:
       ``(iii) the amount determined under subparagraph (C) for 
     each succeeding award year.'';
       (C) by striking subparagraph (C) and inserting the 
     following:
       ``(C) Adjustment amounts.--
       ``(i) Award year 2013-2014.--For award year 2013-2014, the 
     amount determined under this subparagraph for purposes of 
     subparagraph (B)(iii) shall be equal to--

       ``(I) $5,550 or the total maximum Federal Pell Grant for 
     the preceding award year (as determined under clause 
     (v)(II)), whichever is greater, increased by a percentage 
     equal to the annual adjustment percentage for award year 
     2013-2014; reduced by
       ``(II) $4,860 or the maximum Federal Pell Grant for which a 
     student was eligible for the preceding award year, as 
     specified in the last enacted appropriation Act applicable to 
     that year, whichever is greater; and
       ``(III) rounded to the nearest $5.

       ``(ii) Award years 2014-2015 through 2017-2018.--For each 
     of the award years 2014-2015 through 2017-2018, the amount 
     determined under this subparagraph for purposes of 
     subparagraph (B)(iii) shall be equal to--

       ``(I) the total maximum Federal Pell Grant for the 
     preceding award year (as determined under clause (v)(II)), 
     increased by a percentage equal to the annual adjustment 
     percentage for the award year for which the amount under this 
     subparagraph is being determined; reduced by
       ``(II) $4,860 or the maximum Federal Pell Grant for which a 
     student was eligible for the preceding award year, as 
     specified in the last enacted appropriation Act applicable to 
     that year, whichever is greater; and
       ``(III) rounded to the nearest $5.

       ``(iii) Subsequent award years.--For award year 2018-2019 
     and each subsequent award year, the amount determined under 
     this subparagraph for purposes of subparagraph (B)(iii) shall 
     be equal to the amount determined under clause (ii) for award 
     year 2017-2018.
       ``(iv) Limitation on decreases.--Notwithstanding clauses 
     (i), (ii), and (iii), if the amount determined under clause 
     (i), (ii), or (iii) for a particular award year is less than 
     the amount determined under this paragraph for the award year 
     preceding that particular award year, then the amount 
     determined under such clause for that particular award year 
     shall be the amount determined under this paragraph for the 
     preceding award year.
       ``(v) Definitions.--For purposes of this subparagraph--

       ``(I) the term `annual adjustment percentage' as applied to 
     an award year, is equal to the estimated percentage change in 
     the Consumer Price Index (as determined by the Secretary, 
     using the definition in section 478(f)) for the most recent 
     calendar year ending prior to the beginning of that award 
     year; and
       ``(II) the term `total maximum Federal Pell Grant' as 
     applied to a preceding award year, is equal to the sum of--

       ``(aa) the maximum Federal Pell Grant for which a student 
     is eligible during an award year, as specified in the last 
     enacted appropriation Act applicable to that preceding award 
     year; and
       ``(bb) the amount of the increase in the maximum Federal 
     Pell Grant required by this paragraph for that preceding 
     award year.'';
       (D) by striking subparagraph (E); and
       (E) by redesignating subparagraph (F) as subparagraph (E).
       (b) Conforming Amendments.--Title IV (20 U.S.C. 1070 et 
     seq.) is further amended--
       (1) in section 401(b) (20 U.S.C. 1070a(b))--
       (A) in paragraph (4)--
       (i) by striking ``maximum basic grant level specified in 
     the appropriate appropriation Act'' and inserting ``maximum 
     amount of a Federal Pell Grant award determined under 
     paragraph (2)(A)''; and
       (ii) by striking ``such level'' each place it appears and 
     inserting ``such Federal Pell Grant amount'' in each such 
     place; and
       (B) in paragraph (6), by striking ``the grant level 
     specified in the appropriate Appropriation Act for this 
     subpart for such year'' and inserting ``the maximum amount of 
     a Federal Pell Grant award determined under paragraph (2)(A), 
     for which a student is eligible during such award year'';
       (2) in section 402D(d)(1) (20 U.S.C. 1070a-14(d)(1)), by 
     striking ``exceed the maximum'' and all that follows through 
     ``Grant, for'' and

[[Page 4457]]

     inserting ``exceed the Federal Pell Grant amount, determined 
     under section 401(b)(2)(A), for which a student is eligible, 
     or be less than the minimum Federal Pell Grant amount 
     described in section 401(b)(4), for'';
       (3) in section 435(a)(5)(A)(i)(I) (20 U.S.C. 
     1085(a)(5)(A)(i)(I)), by striking ``one-half the maximum 
     Federal Pell Grant award for which a student would be 
     eligible'' and inserting ``one-half the Federal Pell Grant 
     amount, determined under section 401(b)(2)(A), for which a 
     student would be eligible'';
       (4) in section 483(e)(3)(A)(ii) (20 U.S.C. 
     1090(e)(3)(A)(ii)), by striking ``based on the maximum 
     Federal Pell Grant award at the time of application'' and 
     inserting ``based on the Federal Pell Grant amount, 
     determined under section 401(b)(2)(A), for which a student is 
     eligible at the time of application'';
       (5) in section 485E(b)(1)(A) (20 U.S.C. 1092f(b)(1)(A)), by 
     striking ``of such students' potential eligibility for a 
     maximum Federal Pell Grant under subpart 1 of part A'' and 
     inserting ``of such students' potential eligibility for the 
     Federal Pell Grant amount, determined under section 
     401(b)(2)(A), for which the student would be eligible''; and
       (6) in section 894(f)(2)(C)(ii)(I) (20 U.S.C. 
     1161y(f)(2)(C)(ii)(I)), by striking ``the maximum Federal 
     Pell Grant for each award year'' and inserting ``the Federal 
     Pell Grant amount, determined under section 401(b)(2)(A), for 
     which a student may be eligible for each award year''.
       (c) Effective Date.--The amendments made by subsections (a) 
     and (b) shall take effect on July 1, 2010.

     SEC. 2102. COLLEGE ACCESS CHALLENGE GRANT PROGRAM.

       Section 781 (20 U.S.C. 1141) is amended--
       (1) in the first sentence of subsection (a), by striking 
     ``$66,000,000'' and all that follows through the period and 
     inserting ``$150,000,000 for each of the fiscal years 2010 
     through 2014. The authority to award grants under this 
     section shall expire at the end of fiscal year 2014.''; and
       (2) in subsection (c)(2), by striking ``0.5 percent'' and 
     inserting ``1.0 percent''.

     SEC. 2103. INVESTMENT IN HISTORICALLY BLACK COLLEGES AND 
                   UNIVERSITIES AND MINORITY-SERVING INSTITUTIONS.

       Section 371(b)(1)(A) (20 U.S.C. 1067q(b)(1)(A)) is amended 
     by striking ``and 2009.'' and all that follows and inserting 
     ``through 2019. The authority to award grants under this 
     section shall expire at the end of fiscal year 2019.''.

                      PART II--STUDENT LOAN REFORM

     SEC. 2201. TERMINATION OF FEDERAL FAMILY EDUCATION LOAN 
                   APPROPRIATIONS.

       Section 421 (20 U.S.C. 1071) is amended--
       (1) in subsection (b), in the first sentence of the matter 
     following paragraph (6), by inserting ``, except that no sums 
     may be expended after June 30, 2010, with respect to loans 
     under this part for which the first disbursement is after 
     such date'' after ``expended''; and
       (2) by adding at the end the following new subsection:
       ``(d) Termination of Authority To Make or Insure New 
     Loans.--Notwithstanding paragraphs (1) through (6) of 
     subsection (b) or any other provision of law--
       ``(1) no new loans (including consolidation loans) may be 
     made or insured under this part after June 30, 2010; and
       ``(2) no funds are authorized to be appropriated, or may be 
     expended, under this Act or any other Act to make or insure 
     loans under this part (including consolidation loans) for 
     which the first disbursement is after June 30, 2010,

     except as expressly authorized by an Act of Congress enacted 
     after the date of enactment of the SAFRA Act.''.

     SEC. 2202. TERMINATION OF FEDERAL LOAN INSURANCE PROGRAM.

       Section 424(a) (20 U.S.C. 1074(a)) is amended by striking 
     ``September 30, 1976,'' and all that follows and inserting 
     ``September 30, 1976, for each of the succeeding fiscal years 
     ending prior to October 1, 2009, and for the period from 
     October 1, 2009, to June 30, 2010, for loans first disbursed 
     on or before June 30, 2010.''.

     SEC. 2203. TERMINATION OF APPLICABLE INTEREST RATES.

       Section 427A(l) (20 U.S.C. 1077a(l)) is amended--
       (1) in the subsection heading, by inserting ``and Before 
     July 1, 2010'' after ``2006'';
       (2) in paragraph (1), by inserting ``and before July 1, 
     2010,'' after ``July 1, 2006,'';
       (3) in paragraph (2), by inserting ``and before July 1, 
     2010,'' after ``July 1, 2006,'';
       (4) in paragraph (3), by inserting ``and that was disbursed 
     before July 1, 2010,'' after ``July 1, 2006,''; and
       (5) in paragraph (4)--
       (A) in the matter preceding subparagraph (A), by striking 
     ``July 1, 2012'' and inserting ``July 1, 2010''; and
       (B) by repealing subparagraphs (D) and (E).

     SEC. 2204. TERMINATION OF FEDERAL PAYMENTS TO REDUCE STUDENT 
                   INTEREST COSTS.

       (a) Higher Education Act of 1965.--Section 428 (20 U.S.C. 
     1078) is amended--
       (1) in subsection (a)--
       (A) in paragraph (1), in the matter preceding subparagraph 
     (A), by inserting ``for which the first disbursement is made 
     before July 1, 2010, and'' after ``eligible institution''; 
     and
       (B) in paragraph (5), by striking ``September 30, 2014,'' 
     and all that follows through the period and inserting ``June 
     30, 2010.'';
       (2) in subsection (b)(1)--
       (A) in subparagraph (G)(ii), by inserting ``and before July 
     1, 2010,'' after ``July 1, 2006,''; and
       (B) in subparagraph (H)(ii), by inserting ``and that are 
     first disbursed before July 1, 2010,'' after ``July 1, 
     2006,'';
       (3) in subsection (f)(1)(A)(ii)--
       (A) by striking ``during fiscal years beginning''; and
       (B) by inserting ``and first disbursed before July 1, 
     2010,'' after ``October 1, 2003,''; and
       (4) in subsection (j)(1), by inserting ``, before July 1, 
     2010,'' after ``section 435(d)(1)(D) of this Act shall''.
       (b) College Cost Reduction and Access Act.--Section 303 of 
     the College Cost Reduction and Access Act (Public Law 110-84) 
     is repealed.

     SEC. 2205. TERMINATION OF FFEL PLUS LOANS.

       Section 428B(a)(1) (20 U.S.C. 1078-2(a)(1)) is amended by 
     striking ``A graduate'' and inserting ``Prior to July 1, 
     2010, a graduate''.

     SEC. 2206. FEDERAL CONSOLIDATION LOANS.

       (a) In General.--Section 428C (20 U.S.C. 1078-3) is 
     amended--
       (1) in subsection (a)(4)(A), by inserting ``, and first 
     disbursed before July 1, 2010'' after ``under this part'';
       (2) in subsection (b)--
       (A) in paragraph (1)(E), by inserting before the semicolon 
     ``, and before July 1, 2010''; and
       (B) in paragraph (5), by striking ``In the event that'' and 
     inserting ``If, before July 1, 2010,'';
       (3) in subsection (c)(1)--
       (A) in subparagraph (A)(ii), by inserting ``and that is 
     disbursed before July 1, 2010,'' after ``2006,''; and
       (B) in subparagraph (C), by inserting ``and disbursed 
     before July 1, 2010,'' after ``1994,''; and
       (4) in subsection (e), by striking ``September 30, 2014.'' 
     and inserting ``June 30, 2010. No loan may be made under this 
     section for which the disbursement is on or after July 1, 
     2010.''.
       (b) Temporary Loan Consolidation Authority.--Part D of 
     title IV (20 U.S.C. 1087a et seq.) is amended by inserting 
     after section 459A (20 U.S.C. 1087i) the following:

     ``SEC. 459B. TEMPORARY LOAN CONSOLIDATION AUTHORITY.

       ``(a) Temporary Loan Consolidation Authority.--
       ``(1) In general.--A borrower who has 1 or more loans in 2 
     or more of the categories described in paragraph (2), and who 
     has not yet entered repayment on 1 or more of those loans in 
     any of the categories, may consolidate all of the loans of 
     the borrower that are described in paragraph (2) into a 
     Federal Direct Consolidation Loan during the period described 
     in paragraph (3).
       ``(2) Categories of loans that may be consolidated.--The 
     categories of loans that may be consolidated under paragraph 
     (1) are--
       ``(A) loans made under this part;
       ``(B) loans purchased by the Secretary pursuant to section 
     459A; and
       ``(C) loans made under part B that are held by an eligible 
     lender, as such term is defined in section 435(d).
       ``(3) Time period in which loans may be consolidated.--The 
     Secretary may make a Federal Direct Consolidation Loan under 
     this section to a borrower whose application for such Federal 
     Direct Consolidation Loan is received on or after July 1, 
     2010, and before July 1, 2011.
       ``(b) Terms of Loans.--A Federal Direct Consolidation Loan 
     made under this section shall have the same terms and 
     conditions as a Federal Direct Consolidation Loan made under 
     section 455(g), except that--
       ``(1) in determining the applicable rate of interest on the 
     Federal Direct Consolidation Loan made under this section 
     (other than on a Federal Direct Consolidation Loan described 
     in paragraph (2)), section 427A(l)(3) shall be applied 
     without rounding the weighted average of the interest rate on 
     the loans consolidated to the nearest higher one-eighth of 1 
     percent as described in subparagraph (A) of section 
     427A(l)(3); and
       ``(2) if a Federal Direct Consolidation Loan made under 
     this section that repays a loan which is subject to an 
     interest rate determined under section 427A(g)(2), (j)(2), or 
     (k)(2), then the interest rate for such Federal Direct 
     Consolidation Loan shall be calculated--
       ``(A) by using the applicable rate of interest described in 
     section 427A(g)(2), (j)(2), or (k)(2), respectively; and
       ``(B) in accordance with section 427A(l)(3).''.

     SEC. 2207. TERMINATION OF UNSUBSIDIZED STAFFORD LOANS FOR 
                   MIDDLE-INCOME BORROWERS.

       Section 428H (20 U.S.C. 1078-8) is amended--
       (1) in subsection (a), by inserting ``that are first 
     disbursed before July 1, 2010,'' after ``under this part'';
       (2) in subsection (b)--
       (A) by striking ``Any student'' and inserting ``Prior to 
     July 1, 2010, any student''; and
       (B) by inserting ``for which the first disbursement is made 
     before such date'' after ``unsubsidized Federal Stafford 
     Loan''; and
       (3) in subsection (h), by inserting ``and that are first 
     disbursed before July 1, 2010,'' after ``July 1, 2006,''.

     SEC. 2208. TERMINATION OF SPECIAL ALLOWANCES.

       Section 438 (20 U.S.C. 1087-1) is amended--
       (1) in subsection (b)(2)(I)--
       (A) in the subclause heading, by inserting ``, and before 
     july 1, 2010'' after ``2000'';
       (B) in clause (i), by inserting ``and before July 1, 
     2010,'' after ``2000,'';
       (C) in clause (ii)(II), by inserting ``and before July 1, 
     2010,'' after ``2006,'';
       (D) in clause (iii), by inserting ``and before July 1, 
     2010,'' after ``2000,'';
       (E) in clause (iv), by inserting ``and that is disbursed 
     before July 1, 2010,'' after ``2000,'';

[[Page 4458]]

       (F) in clause (v)(I), by inserting ``and before July 1, 
     2010,'' after ``2006,''; and
       (G) in clause (vi)--
       (i) in the clause heading, by inserting ``, and before july 
     1, 2010'' after ``2007''; and
       (ii) in the matter preceding subclause (I), by inserting 
     ``and before July 1, 2010,'' after ``2007,'';
       (2) in subsection (c)--
       (A) in paragraph (2)(B)--
       (i) in clause (iii), by inserting ``and'' after the 
     semicolon;
       (ii) in clause (iv), by striking ``; and'' and inserting a 
     period; and
       (iii) by striking clause (v); and
       (B) in paragraph (6), by inserting ``and first disbursed 
     before July 1, 2010,'' after ``1992,''; and
       (3) in subsection (d)(2)(B), by inserting ``, and before 
     July 1, 2010'' after ``2007''.

     SEC. 2209. ORIGINATION OF DIRECT LOANS AT INSTITUTIONS 
                   OUTSIDE THE UNITED STATES.

       (a) Loans for Students Attending Institutions Outside the 
     United States.--Section 452 (20 U.S.C. 1087b) is amended by 
     adding at the end the following:
       ``(d) Institutions Outside the United States.--Loan funds 
     for students (and parents of students) attending institutions 
     outside the United States shall be disbursed through a 
     financial institution located or operating in the United 
     States and designated by the Secretary to serve as the agent 
     of such institutions with respect to the receipt of the 
     disbursements of such loan funds and the transfer of such 
     funds to such institutions. To be eligible to receive funds 
     under this part, an institution outside the United States 
     shall make arrangements with the agent designated by the 
     Secretary under this subsection to receive funds under this 
     part.''.
       (b) Conforming Amendments.--
       (1) Amendments.--Section 102 (20 U.S.C. 1002), as amended 
     by section 102 of the Higher Education Opportunity Act 
     (Public Law 110-315) and section 101 of Public Law 111-39, is 
     amended--
       (A) by striking ``part B'' each place the term appears and 
     inserting ``part D'';
       (B) in subsection (a)(1)(C), by inserting ``, consistent 
     with the requirements of section 452(d)'' before the period 
     at the end; and
       (C) in subsection (a)(2)(A)--
       (i) in the second sentence of the matter preceding clause 
     (i), by striking ``made, insured, or guaranteed'' and 
     inserting ``made''; and
       (ii) in clause (iii)--

       (I) in subclause (III), by striking ``only Federal 
     Stafford'' and all that follows through ``section 428B'' and 
     inserting ``only Federal Direct Stafford Loans under section 
     455(a)(2)(A), Federal Direct Unsubsidized Stafford Loans 
     under section 455(a)(2)(D), or Federal Direct PLUS Loans 
     under section 455(a)(2)(B)''; and
       (II) in subclause (V), by striking ``a Federal Stafford'' 
     and all that follows through ``section 428B'' and inserting 
     ``a Federal Direct Stafford Loan under section 455(a)(2)(A), 
     a Federal Direct Unsubsidized Stafford Loan under section 
     455(a)(2)(D), or a Federal Direct PLUS Loan under section 
     455(a)(2)(B)''.

       (2) Effective date.--The amendments made by subparagraph 
     (C) of paragraph (1) shall be effective on July 1, 2010, as 
     if enacted as part of section 102(a)(1) of the Higher 
     Education Opportunity Act (Public Law 110-315) and subject to 
     section 102(e) of such Act as amended by section 101(a)(2) of 
     Public Law 111-39 (20 U.S.C. 1002 note).

     SEC. 2210. CONFORMING AMENDMENTS.

       (a) Amendments.--Section 454 (20 U.S.C. 1087d) is amended--
       (1) in subsection (a)--
       (A) by striking paragraph (4); and
       (B) by redesignating paragraphs (5) through (7) as 
     paragraphs (4) through (6), respectively; and
       (2) in subsection (b)(2), by striking ``(5), (6), and (7)'' 
     and inserting ``(5), and (6)''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect on July 1, 2010.

     SEC. 2211. TERMS AND CONDITIONS OF LOANS.

       (a) In General.--Section 455 (20 U.S.C. 1087e) is amended--
       (1) in subsection (a)(1), by inserting ``, and first 
     disbursed on June 30, 2010,'' before ``under sections 428''; 
     and
       (2) in subsection (g)--
       (A) by inserting ``, including any loan made under part B 
     and first disbursed before July 1, 2010'' after ``section 
     428C(a)(4)''; and
       (B) by striking the third sentence.
       (b) Effective Date.--The amendment made by subsection 
     (a)(1) shall apply with respect to loans first disbursed 
     under part D of title IV of the Higher Education Act of 1965 
     (20 U.S.C. 1087a et seq.) on or after July 1, 2010.

     SEC. 2212. CONTRACTS; MANDATORY FUNDS.

       (a) Contracts.--Section 456 (20 U.S.C. 1087f) is amended--
       (1) in subsection (a)--
       (A) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) Servicing by eligible not-for-profit servicers.--
       ``(A) Servicing contracts.--
       ``(i) In general.--The Secretary shall contract with each 
     eligible not-for-profit servicer to service loans originated 
     under this part, if the servicer--

       ``(I) meets the standards for servicing Federal assets that 
     apply to contracts awarded pursuant to paragraph (1); and
       ``(II) has the capacity to service the applicable loan 
     volume allocation described in subparagraph (B).

       ``(ii) Competitive market rate determination for first 
     100,000 borrower accounts.--The Secretary shall establish a 
     separate pricing tier for each of the first 100,000 borrower 
     loan accounts at a competitive market rate.
       ``(iii) Ineligibility.--An eligible not-for-profit servicer 
     shall no longer be eligible for a contract under this 
     paragraph after July 1, 2014, if--

       ``(I) the servicer has not been awarded such a contract 
     before that date; or
       ``(II) the servicer's contract was terminated, and the 
     servicer had not reapplied for, and been awarded, a contract 
     under this paragraph.

       ``(B) Allocations.--
       ``(i) In general.--The Secretary shall (except as provided 
     in clause (ii)) allocate to an eligible not-for-profit 
     servicer, subject to the contract of such servicer described 
     in subparagraph (A), the servicing rights for the loan 
     accounts of 100,000 borrowers (including borrowers who 
     borrowed loans in a prior year that were serviced by the 
     servicer).
       ``(ii) Servicer allocation.--The Secretary may reallocate, 
     increase, reduce, or terminate an eligible not-for-profit 
     servicer's allocation of servicing rights under clause (i) 
     based on the performance of such servicer, on the same terms 
     as loan allocations provided by contracts awarded pursuant to 
     paragraph (1).''; and
       (2) by adding at the end the following:
       ``(c) Definition of Eligible Not-for-Profit Servicer.--In 
     this section:
       ``(1) In general.--The term `eligible not-for-profit 
     servicer' means an entity--
       ``(A) that is not owned or controlled in whole or in part 
     by--
       ``(i) a for profit entity; or
       ``(ii) a nonprofit entity having its principal place of 
     business in another State; and
       ``(B) that--
       ``(i) as of July 1, 2009--

       ``(I) meets the definition of an eligible not-for-profit 
     holder under section 435(p), except that such term does not 
     include eligible lenders described in paragraph (1)(D) of 
     such section; and
       ``(II) was performing, or had entered into a contract with 
     a third party servicer (as such term is defined in section 
     481(c)) who was performing, student loan servicing functions 
     for loans made under part B of this title;

       ``(ii) notwithstanding clause (i), as of July 1, 2009--

       ``(I) is the sole beneficial owner of a loan for which the 
     special allowance rate is calculated under section 
     438(b)(2)(I)(vi)(II) because the loan is held by an eligible 
     lender trustee that is an eligible not-for-profit holder as 
     defined under section 435(p)(1)(D); and
       ``(II) was performing, or had entered into a contract with 
     a third party servicer (as such term is defined in section 
     481(c)) who was performing, student loan servicing functions 
     for loans made under part B of this title; or

       ``(iii) is an affiliated entity of an eligible not-for-
     profit servicer described in clause (i) or (ii) that--

       ``(I) directly employs, or will directly employ (on or 
     before the date the entity begins servicing loans under a 
     contract awarded by the Secretary pursuant to subsection 
     (a)(3)(A)), the majority of individuals who perform borrower-
     specific student loan servicing functions; and
       ``(II) as of July 1, 2009, was performing, or had entered 
     into a contract with a third party servicer (as such term is 
     defined in section 481(c)) who was performing, student loan 
     servicing functions for loans made under part B of this 
     title.

       ``(2) Affiliated entity.--For the purposes of paragraph 
     (1), the term `affiliated entity'--
       ``(A) means an entity contracted to perform services for an 
     eligible not-for-profit servicer that--
       ``(i) is a nonprofit entity or is wholly owned by a 
     nonprofit entity; and
       ``(ii) is not owned or controlled, in whole or in part, 
     by--

       ``(I) a for-profit entity; or

       ``(II) an entity having its principal place of business in 
     another State; and

       ``(B) may include an affiliated entity that is established 
     by an eligible not-for-profit servicer after the date of 
     enactment of the SAFRA Act, if such affiliated entity is 
     otherwise described in paragraph (1)(B)(iii)(I) and 
     subparagraph (A) of this paragraph.''.
       (b) Mandatory Funds.--
       (1) Amendments.--Section 458(a) (20 U.S.C. 1087h(a)) is 
     amended--
       (A) by redesignating paragraph (5) as paragraph (8);
       (B) by redesignating paragraphs (2) through (4) as 
     paragraphs (3) through (5), respectively;
       (C) by inserting after paragraph (1) the following new 
     paragraph:
       ``(2) Mandatory funds for eligible not-for-profit-
     servicers.--For fiscal years 2010 through 2019, there shall 
     be available to the Secretary, in addition to any other 
     amounts appropriated to carry out this paragraph and out of 
     any money in the Treasury not otherwise appropriated, funds 
     to be obligated for administrative costs of servicing 
     contracts with eligible not-for-profit servicers as described 
     in section 456.''; and
       (D) by inserting after paragraph (5), as redesignated by 
     subparagraph (B) of this paragraph, the following:
       ``(6) Technical assistance to institutions of higher 
     education.--
       ``(A) Provision of assistance.--The Secretary shall provide 
     institutions of higher education participating, or seeking to 
     participate, in the loan programs under this part with 
     technical assistance in establishing and administering such 
     programs.

[[Page 4459]]

       ``(B) Funds.--There are authorized to be appropriated, and 
     there are appropriated, to carry out this paragraph (in 
     addition to any other amounts appropriated to carry out this 
     paragraph and out of any money in the Treasury not otherwise 
     appropriated), $50,000,000 for fiscal year 2010.
       ``(C) Definition.--In this paragraph, the term `assistance' 
     means the provision of technical support, training, 
     materials, technical assistance, and financial assistance.
       ``(7) Additional payments.--
       ``(A) Provision of assistance.--The Secretary shall provide 
     payments to loan servicers for retaining jobs at locations in 
     the United States where such servicers were operating under 
     part B on January 1, 2010.
       ``(B) Funds.--There are authorized to be appropriated, and 
     there are appropriated, to carry out this paragraph (in 
     addition to any other amounts appropriated to carry out this 
     paragraph and out of any money in the Treasury not otherwise 
     appropriated), $25,000,000 for each of the fiscal years 2010 
     and 2011.''.
       (2) Conforming amendment.--Section 458 (20 U.S.C. 1087h) is 
     further amended by striking ``subsection (a)(3)'' in 
     subsection (b) and inserting ``subsection (a)(4)''.

     SEC. 2213. INCOME-BASED REPAYMENT.

       Section 493C (20 U.S.C. 1098e) is amended by adding at the 
     end the following new subsection:
       ``(e) Special Terms for New Borrowers on and After July 1, 
     2014.--With respect to any loan made to a new borrower on or 
     after July 1, 2014--
       ``(1) subsection (a)(3)(B) shall be applied by substituting 
     `10 percent' for `15 percent'; and
       ``(2) subsection (b)(7)(B) shall be applied by substituting 
     `20 years' for `25 years'.''.

                           Subtitle B--Health

     SEC. 2301. INSURANCE REFORMS.

       (a) Extending Certain Insurance Reforms to Grandfathered 
     Plans.--Section 1251(a) of the Patient Protection and 
     Affordable Care Act, as added by section 10103(d) of such 
     Act, is amended by adding at the end the following:
       ``(4) Application of certain provisions.--
       ``(A) In general.--The following provisions of the Public 
     Health Service Act (as added by this title) shall apply to 
     grandfathered health plans for plan years beginning with the 
     first plan year to which such provisions would otherwise 
     apply:
       ``(i) Section 2708 (relating to excessive waiting periods).
       ``(ii) Those provisions of section 2711 relating to 
     lifetime limits.
       ``(iii) Section 2712 (relating to rescissions).
       ``(iv) Section 2714 (relating to extension of dependent 
     coverage).
       ``(B) Provisions applicable only to group health plans.--
       ``(i) Provisions described.--Those provisions of section 
     2711 relating to annual limits and the provisions of section 
     2704 (relating to pre-existing condition exclusions) of the 
     Public Health Service Act (as added by this subtitle) shall 
     apply to grandfathered health plans that are group health 
     plans for plan years beginning with the first plan year to 
     which such provisions otherwise apply.
       ``(ii) Adult child coverage.--For plan years beginning 
     before January 1, 2014, the provisions of section 2714 of the 
     Public Health Service Act (as added by this subtitle) shall 
     apply in the case of an adult child with respect to a 
     grandfathered health plan that is a group health plan only if 
     such adult child is not eligible to enroll in an eligible 
     employer-sponsored health plan (as defined in section 
     5000A(f)(2) of the Internal Revenue Code of 1986) other than 
     such grandfathered health plan.''.
       (b) Clarification Regarding Dependent Coverage.--Section 
     2714(a) of the Public Health Service Act, as added by section 
     1001(5) of the Patient Protection and Affordable Care Act, is 
     amended by striking ``(who is not married)''.

     SEC. 2302. DRUGS PURCHASED BY COVERED ENTITIES.

       Section 340B of the Public Health Service Act (42 U.S.C. 
     256b), as amended by sections 7101 and 7102 of the Patient 
     Protection and Affordable Care Act, is amended--
       (1) in subsection (a)--
       (A) in paragraphs (1), (2), (5), (7), and (9), by striking 
     the terms ``covered drug'' and ``covered drugs'' each place 
     either term appears and inserting ``covered outpatient drug'' 
     or ``covered outpatient drugs'', respectively;
       (B) in paragraph (4)(L)--
       (i) in clause (i), by striking ``and'' at the end;
       (ii) in clause (ii), by striking the period and inserting 
     ``; and''; and
       (iii) by inserting after clause (ii), the following:
       ``(iii) does not obtain covered outpatient drugs through a 
     group purchasing organization or other group purchasing 
     arrangement.''; and
       (C) in paragraph (5)--
       (i) by striking subparagraph (C);
       (ii) by redesignating subparagraphs (D) and (E) as 
     subparagraphs (C) and (D), respectively; and
       (iii) in subparagraph (D), as so redesignated, by striking 
     ``subparagraph (D)'' and inserting ``subparagraph (C)'';
       (2) by striking subsection (c);
       (3) in subsection (d)--
       (A) by striking ``covered drugs'' each place it appears and 
     inserting ``covered outpatient drugs'';
       (B) by striking ``(a)(5)(D)'' each place it appears and 
     inserting ``(a)(5)(C)''; and
       (C) by striking ``(a)(5)(E)'' each place it appears and 
     inserting ``(a)(5)(D)''; and
       (4) by inserting after subsection (d) the following:
       ``(e) Exclusion of Orphan Drugs for Certain Covered 
     Entities.--For covered entities described in subparagraph 
     (M), (N), or (O) of subsection (a)(4), the term `covered 
     outpatient drug' shall not include a drug designated by the 
     Secretary under section 526 of the Federal Food, Drug, and 
     Cosmetic Act for a rare disease or condition.''.

     SEC. 2303. COMMUNITY HEALTH CENTERS.

       Section 10503(b)(1) of the Patient Protection and 
     Affordable Care Act is amended--
       (1) in subparagraph (A), by striking ``700,000,000'' and 
     inserting ``1,000,000,000'';
       (2) in subparagraph (B), by striking ``800,000,000'' and 
     inserting ``1,200,000,000'';
       (3) in subparagraph (C), by striking ``1,000,000,000'' and 
     inserting ``1,500,000,000'';
       (4) in subparagraph (D), by striking ``1,600,000,000'' and 
     inserting ``2,200,000,000''; and
       (5) in subparagraph (E), by striking ``2,900,000,000'' and 
     inserting ``3,600,000,000''.
  The SPEAKER pro tempore. Pursuant to House Resolution 1203, the 
previous question is ordered on the bill, as amended.
  The question is on the engrossment and third reading of the bill.
  The bill was ordered to be engrossed and read a third time, and was 
read the third time.


                           Motion to Recommit

  Mr. CAMP. Mr. Speaker, I have a motion to recommit at the desk.
  The SPEAKER pro tempore. Is the gentleman opposed to the bill?
  Mr. CAMP. In its current form.
  The SPEAKER pro tempore. The Clerk will designate the motion.
  The text of the motion is as follows:
  Motion to recommit offered by Mr. Camp:
       Mr. Camp moves to recommit the bill H.R. 4872 to the 
     Committee on the Budget with instructions to report the same 
     back to the House forthwith with the following amendments:
       Add at the end of section 1002 (relating to individual 
     responsibility) the following:
       (c) Application of Penalty.--Section 5000A(g)(1) of the 
     Internal Revenue Code of 1986, as added by section 1501(b) of 
     the Patient Protection and Affordable Care Act and amended by 
     section 10106 of such Act, is amended to read as follows:
       ``(1) In general.--The penalty provided by this section 
     shall be paid upon notice and demand by the Secretary, and 
     except as provided in paragraph (2), shall be assessed and 
     collected in the same manner as an assessable penalty under 
     subchapter B of chapter 68. The penalties provided by this 
     section shall, subject to appropriations, be deposited by the 
     Secretary in the the Trust Funds established under title II 
     of the Social Security Act (in such proportions as the 
     Secretary shall specify). The value of such Trust Funds shall 
     be calculated each year as if the amounts described in the 
     previous sentence had been appropriated and deposited into 
     such Trust Funds.''.
       At the end of subtitle A of title I, add the following:

     SEC. 1006. SPECIAL RULES RELATING TO COVERAGE OF ABORTION 
                   SERVICES.

       (a) In General.--Section 1303 of the Patient Protection and 
     Affordable Care Act, as amended by section 10104(c) of such 
     Act, is amended--
       (1) in the section heading, by inserting ``RELATING TO 
     COVERAGE OF ABORTION SERVICES'' after ``SPECIAL RULES''; and
       (2) by striking subsection (a) and all of subsection (b) 
     that precedes paragraph (4) and inserting the following:
       ``(a) In General.--Nothing in this Act (or any amendment 
     made by this Act) shall be construed to require any health 
     plan to provide coverage of abortion services or to allow the 
     Secretary or any other person or entity implementing this Act 
     (or amendment) to require coverage of such services.
       ``(b) Limitation on Abortion Funding.--
       ``(1) In general.--None of the funds authorized or 
     appropriated by this Act (or an amendment made by this Act), 
     including credits under section 36B of the Internal Revenue 
     Code of 1986, shall be expended for any abortion or to cover 
     any part of the costs of any health plan that includes 
     coverage of abortion, except in the case where a woman 
     suffers from a physical disorder, physical injury, or 
     physical illness that would, as certified by a physician, 
     place the woman in danger of death unless an abortion is 
     performed, including a life-endangering physical condition 
     caused by or arising from the pregnancy itself, or unless the 
     pregnancy is the result of an act of rape or incest.
       ``(2) Option to purchase separate coverage or plan.--
     Subject to paragraph (1), nothing in this subsection shall be 
     construed as prohibiting any non-Federal entity (including an 
     individual or a State or local government) from purchasing 
     separate coverage for abortions for which funding is 
     prohibited under this subsection, or a plan that includes 
     such abortions, so long as such coverage or plan is not 
     purchased using the non-Federal funds required to receive a 
     Federal payment, including a premium payment required for a 
     qualified health plan towards which the credit described in 
     paragraph (1) is applied or a

[[Page 4460]]

     State's or locality's contribution of Medicaid matching 
     funds.
       ``(3) Option to offer coverage or plan.--Subject to 
     paragraph (1), nothing in this subsection shall restrict any 
     non-Federal health insurance issuer offering a qualified 
     health plan from offering separate coverage for abortions for 
     which funding is prohibited under this subsection, or a plan 
     that includes such abortions, so long as any such issuer that 
     offers a qualified health plan through an Exchange that 
     includes coverage for abortions for which funding is 
     prohibited under this subsection also offers a qualified 
     health plan through the Exchange that is identical in every 
     respect except that it does not cover such abortions.''.
       (b) Conforming Amendment for Multi-State Plans.--Section 
     1334(a) of the Patient Protection and Affordable Care Act, as 
     added by section 10104(q) of such Act, is amended by striking 
     paragraph (6) and redesignating paragraph (7) as paragraph 
     (6).

  The SPEAKER pro tempore. Pursuant to the rule, the gentleman from 
Michigan is recognized for 5 minutes in support of his motion.
  Mr. HOYER. Mr. Speaker, is the motion going to be read?
  The SPEAKER pro tempore. The rule dispenses with the reading. The 
motion is merely designated.
  The gentleman from Michigan is recognized for 5 minutes.
  Mr. CAMP. As the previous vote shows, there is bipartisan opposition 
to the health care bill the Senate sent to this House. It is with good 
reason. The American people, Republicans and a few brave Democrats--34, 
to be exact--34 brave Democrats have rejected it precisely because of 
the legislation's deep flaws. The motion to recommit offers us a chance 
to fix the most egregious defect, allowing taxpayer funds to subsidize 
abortions.
  Mr. Speaker, the very strict rules of the House waive the reading of 
all of these rules and motions, but this motion ensures the Hyde 
language remains the law of the land. The latest in a long string of 
deals--the one made today with the President--does not protect the life 
of unborn children. As the gentleman from Mississippi, a Democrat, 
warned earlier today, anything the President does by Executive order, 
he can undo by Executive order.
  There is no bargaining or dealmaking when it comes to the life of the 
unborn. A life is a life. And it is the responsibility of this House to 
defend these children.
  When this measure was last before the House, it passed 
overwhelmingly, 240-194. It should do so again.
  I now yield to the gentleman from Pennsylvania (Mr. Pitts) to further 
discuss this motion to recommit.
  Mr. PITTS. I rise in support of the motion before us. Over and over 
again, polls have shown the public does not support Federal funding of 
abortions. Unfortunately, the Senate rejected the will of the people 
and passed a bill that has become known as the most massively pro-
abortion piece of legislation to come before Congress since Roe v. 
Wade.
  Despite the political runaround that we've been given this last week, 
the facts remain before us today: The Senate bill departs from 
longstanding current policy and achieves the exact opposite effect of 
current law, and an Executive order promised by the President will not 
change these facts. An Executive order does not trump a statute. The 
courts will undoubtedly look to the legislative text to interpret the 
law.
  Moreover, the promised order fails to even correct the egregious pro-
life concerns contained in this bill. It will simply reiterate the 
meaningless accounting scheme cooked up by the Senate bill. Regardless 
of what type of gimmick is employed to facilitate the abortion 
payments, the result will be the same. The abortion rate will rise and 
more unborn lives will be lost.
  The Executive order does nothing to prevent funding for abortion in 
the co-op program or prevent funding for abortion in the high-risk 
insurance pool program. The Executive order does not prevent HRSA from 
issuing regs that include abortion as a preventive service, thereby 
mandating all individual plans and group plans include abortion as a 
required service. The Executive order does nothing to prevent that 
abortion surcharge mandate from being implemented. It is full of 
loopholes.
  Mr. Speaker, I urge my colleagues to reinstate the pro-life 
protections that passed this Chamber last November in a bipartisan 
vote, the Stupak-Pitts amendment. I urge my colleagues to vote ``yes'' 
on this motion.
  Mr. CAMP. Mr. Speaker, I now yield to the gentleman from New Jersey 
(Mr. Smith).
  Mr. SMITH of New Jersey. Mr. Speaker, in a dramatic reversal of 
current law, ObamaCare, as just passed, authorizes health insurance 
policies funded with tax credits and cost reduction payments to pay for 
abortion on demand and forces the issuers of federally subsidized plans 
to collect a new abortion fee and abortion surtax from every enrollee 
to pay for other people's abortions. Insurance companies need only 
segregate the funds--a mere bookkeeping exercise--to subsidize 
unrestricted, publicly funded abortions.
  OPM will also administer multi-State insurance plans with abortion, 
another radical departure from the status quo. What of the Executive 
order? With all due respect, what a joke. It does absolutely nothing to 
mitigate or change in any way the huge expansion of public funding of 
abortion.
  For example--and I ask Members to read it--section 2 only directs 
officials, pursuant to provisions of the bill just passed, to establish 
a model set of segregation guidelines. So, in other words, the abortion 
expansion is unabated.
  I ask Members to support Stupak-Pitts and the motion to recommit.
  Mr. HOYER. Mr. Speaker, I rise in opposition to the motion.
  The SPEAKER pro tempore. The gentleman from Maryland is recognized 
for 5 minutes.
  Mr. HOYER. I thank the Speaker.
  Ladies and gentlemen, we have come a far pace. The majority of this 
House has just voted to do for Americans what a hundred years of 
Presidents have asked for. We are on the cusp of a great victory for 
America and for Americans. This motion is inconsistent with 
reconciliation, a process that 72 percent of the time was pursued by 
the other party. They know that this motion is not in order and they 
know this motion would not have support in the Senate, so they are 
indirectly trying to kill this bill. However, as well, I think they 
well misstate the case.
  I yield to the gentleman from Michigan.

                              {time}  2300

  Mr. STUPAK. I thank the gentleman for yielding.
  The motion to recommit purports to be a right-to-life motion, in the 
spirit of the Stupak amendment. But as the author of the Stupak 
amendment, this motion is nothing more than an opportunity to continue 
to deny 32 million Americans health care. The motion is really a last-
ditch effort of 98 years of denying Americans health care.
  The motion to recommit does not promote life. It is the Democrats who 
have stood up for the principle of no public funding for abortions. It 
is Democrats, through the President's executive order, that ensures the 
sanctity of life is protected, because all life is precious and all 
life should be honored. Democrats guarantee all life from the unborn to 
the last breath of a senior citizen is honored and respected. For the 
unborn child, his or her mother will finally have pre-and postnatal 
care under our bill. If the child is born with mental problems, we 
provide medical care without bankrupting the family.
  For the Republicans to now claim that we send the bill back to 
committee under the guise of protecting life is disingenuous. This 
motion is really to politicize life, not prioritize life. We stand for 
the American people. We stand up for life. Vote ``no'' on this motion 
to recommit.
  Mr. HOYER. My colleagues, we have come this far not to be thwarted by 
a procedural motion that will never have effect. They know that. We 
know that. Vote ``no.'' Vote ``yes'' for the health care of all 
America.
  I yield back the balance of my time.
  The SPEAKER pro tempore. Without objection, the previous question is 
ordered on the motion to recommit.
  There was no objection.
  The SPEAKER pro tempore. The question is on the motion to recommit.

[[Page 4461]]

  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.


                             Recorded Vote

  Mr. CAMP. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The vote was taken by electronic device, and there were--ayes 199, 
noes 232, not voting 0, as follows:

                             [Roll No. 166]

                               AYES--199

     Aderholt
     Akin
     Alexander
     Altmire
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Barrow
     Bartlett
     Barton (TX)
     Berry
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boustany
     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Carter
     Cassidy
     Castle
     Chaffetz
     Chandler
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Costello
     Crenshaw
     Culberson
     Davis (KY)
     Davis (TN)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Donnelly (IN)
     Dreier
     Duncan
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hoekstra
     Holden
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     Lipinski
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     Marshall
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McIntyre
     McKeon
     McMorris Rodgers
     Melancon
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Ross
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuler
     Shuster
     Simpson
     Skelton
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Sullivan
     Taylor
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                               NOES--232

     Ackerman
     Adler (NJ)
     Andrews
     Arcuri
     Baca
     Baird
     Baldwin
     Bean
     Becerra
     Berkley
     Berman
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Doyle
     Driehaus
     Edwards (MD)
     Edwards (TX)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kosmas
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McMahon
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Miller, George
     Minnick
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Pelosi
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Sires
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Tanner
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                              {time}  2319

  So the motion to recommit was rejected.
  The result of the vote was announced as above recorded.
  The SPEAKER pro tempore. The question is on the passage of the bill.
  The question was taken; and the Speaker pro tempore announced that 
the ayes appeared to have it.


                             Recorded Vote

  Mr. DINGELL. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, this 15-
minute vote on passage of the bill will be followed by 5-minute votes 
on motions to suspend the rules with regard to House Resolution 1099 
and House Resolution 1119.
  The vote was taken by electronic device, and there were--ayes 220, 
noes 211, not voting 0, as follows:

                             [Roll No. 167]

                               AYES--220

     Ackerman
     Andrews
     Baca
     Baird
     Baldwin
     Bean
     Becerra
     Berkley
     Berman
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boswell
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (CA)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Klein (FL)
     Kosmas
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Lipinski
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Miller, George
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Nadler (NY)
     Napolitano
     Neal (MA)
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Pelosi
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Sires
     Slaughter
     Smith (WA)
     Snyder
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                               NOES--211

     Aderholt
     Adler (NJ)
     Akin
     Alexander
     Altmire
     Arcuri
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Barrow
     Bartlett
     Barton (TX)
     Berry
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boucher
     Boustany

[[Page 4462]]


     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Carter
     Cassidy
     Castle
     Chaffetz
     Chandler
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Cooper
     Crenshaw
     Culberson
     Davis (AL)
     Davis (KY)
     Davis (TN)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Edwards (TX)
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Herseth Sandlin
     Hoekstra
     Holden
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kissell
     Kline (MN)
     Kratovil
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     Marshall
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McIntyre
     McKeon
     McMahon
     McMorris Rodgers
     Melancon
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Minnick
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Nye
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Ross
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuler
     Shuster
     Simpson
     Skelton
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Space
     Stearns
     Sullivan
     Tanner
     Taylor
     Teague
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                              {time}  2337

  So the bill was passed.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.

                          ____________________