[Congressional Record (Bound Edition), Volume 156 (2010), Part 4]
[Senate]
[Pages 4676-4685]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           TEXT OF AMENDMENTS

  SA 3556. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle D of title I, add the following:

     SEC. 1306. REDUCING HEALTH CARE COSTS BY ELIMINATING PAYMENTS 
                   FOR FRAUDULENT CLAIMS AND PROHIBITING COVERAGE 
                   FOR ABORTION DRUGS AND ERECTILE DYSFUNCTION 
                   DRUGS FOR RAPISTS AND CHILD MOLESTERS.

       (a) Eliminating Fraudulent Payments for Prescription 
     Drugs.--The Secretary shall establish a fraud prevention 
     system and issue guidance to--
       (1) prevent the processing of claims of prescribing 
     providers and dispensing pharmacies debarred from Federal 
     contracts or excluded from the Medicare program under title 
     XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) or 
     the Medicaid program under title XIX of such Act (42 U.S.C. 
     1396 et seq.);
       (2) ensure that drug utilization reviews and restricted 
     recipient program requirements adequately identify and 
     prevent doctor shopping and other abuses of controlled 
     substances;
       (3) develop a claims processing system to identify 
     duplicate enrollments and deaths of Medicaid beneficiaries 
     and prevent the approval of fraudulent claims; and
       (4) develop a claims processing systems to identify deaths 
     of Medicaid providers and prevent the approval of fraudulent 
     claims filed using the identity of such providers.
       (b) Prohibiting Coverage of Certain Prescription Drugs.--
       (1) In general.--Health programs administered by the 
     Federal Government and American Health Benefit Exchanges (as 
     described in section 1311 of the Patient Protection and 
     Affordable Care Act) shall not provide coverage or 
     reimbursement for--
       (A) prescription drugs to treat erectile dysfunction for 
     individuals convicted of child molestation, rape, or other 
     forms of sexual assault; or
       (B) drugs prescribed with the intent of inducing an 
     abortion for reasons other than as described in paragraph 
     (2).
       (2) Exceptions.--The limitation under paragraph (1)(B) 
     shall not apply to an abortion--
       (A) 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
       (B) if the pregnancy is the result of an act of forcible 
     rape or incest.
                                 ______
                                 
  SA 3557. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title II, add the following:

     SEC. 2304. BUREAUCRAT LIMITATION.

       For each new bureaucrat added to any department or agency 
     of the Federal Government for the purpose of implementing the 
     provisions of the Patient Protection and Affordable Care Act 
     (or any amendment made by such Act), the head of such 
     department or agency shall ensure that the addition of such 
     new bureaucrat is offset by a reduction of 1 existing 
     bureaucrat at such department or agency.
                                 ______
                                 
  SA 3558. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title II, add the following:

     SECTION 2304. LIMITATION OF POWERS OF THE SECRETARY.

       Notwithstanding any other provision of law, the Secretary 
     of Health and Human Services shall have no power or authority 
     other than such power and authority granted by statute and in 
     effect before January 1, 2010.
                                 ______
                                 
  SA 3559. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       Strike subsection (a) of section 2301.
                                 ______
                                 
  SA 3560. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:
       At the end of title I, add the following:

 Subtitle G--Additional Provisions Eliminating Waste, Fraud, and Abuse

     SEC. 1601. SITE INSPECTIONS; BACKGROUND CHECKS; DENIAL AND 
                   SUSPENSION OF BILLING PRIVILEGES.

       (a) Site Inspections for DME Suppliers, Community Mental 
     Health Centers, and Other Provider Groups.--Title XVIII of 
     the Social Security Act (42 U.S.C. 1395 et seq.), as amended 
     by sections 3022 and 3403 of the Patient Protection and 
     Affordable Care Act, is amended by adding at the end the 
     following:


``site inspections for dme suppliers, community mental health centers, 
                       and other provider groups

       ``Sec. 1899B.  (a) Site Inspections.--
       ``(1) In general.--The Secretary shall conduct a site 
     inspection for each applicable provider (as defined in 
     paragraph (2)) that applies to enroll under this title in 
     order to provide items or services under this title. Such 
     site inspection shall be in addition to any other site 
     inspection that the Secretary would otherwise conduct with 
     regard to an applicable provider.
       ``(2) Applicable provider defined.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     in this section the term `applicable provider' means--
       ``(i) a supplier of durable medical equipment (including 
     items described in section 1834(a)(13));
       ``(ii) a supplier of prosthetics, orthotics, or supplies 
     (including items described in paragraphs (8) and (9) of 
     section 1861(s));
       ``(iii) a community mental health center; or
       ``(iv) any other provider group, as determined by the 
     Secretary (including suppliers, both participating suppliers 
     and non-participating suppliers, as such terms are defined 
     for purposes of section 1842).
       ``(B) Exception.--In this section, the term `applicable 
     provider' does not include--
       ``(i) a physician that provides durable medical equipment 
     (as described in subparagraph (A)(i)) or prosthetics, 
     orthotics, or supplies (as described in subparagraph (A)(ii)) 
     to an individual as incident to an office visit by such 
     individual; or
       ``(ii) a hospital that provides durable medical equipment 
     (as described in subparagraph (A)(i)) or prosthetics, 
     orthotics, or supplies (as described in subparagraph (A)(ii)) 
     to an individual as incident to an emergency room visit by 
     such individual.
       ``(b) Standards and Requirements.--In conducting the site 
     inspection pursuant to subsection (a), the Secretary shall 
     ensure that the site being inspected is in full compliance 
     with all the conditions and standards of participation and 
     requirements for obtaining billing privileges under this 
     title.
       ``(c) Time.--The Secretary shall conduct the site 
     inspection for an applicable provider prior to the issuance 
     of billing privileges under this title to such provider.
       ``(d) Timely Review.--The Secretary shall provide for 
     procedures to ensure that the site inspection required under 
     this section does not unreasonably delay the issuance of 
     billing privileges under this title to an applicable 
     provider.''.
       (b) Background Checks.--Title XVIII of the Social Security 
     Act (42 U.S.C. 1395 et seq.) (as amended by subsection (a)) 
     is amended by adding at the end the following new section:


    ``background checks; denial and suspension of billing privileges

       ``Sec. 1899C.  (a) Background Check Required.--Except as 
     provided in subsection (b), in addition to any screening 
     conducted under section 1866(j), the Secretary shall conduct 
     a background check on any individual or entity that enrolls 
     under this title for the purpose of furnishing any item or 
     service under this title, including any individual or entity 
     that is a supplier, a person with an ownership or control 
     interest, a managing employee (as defined in section 
     1126(b)), or an authorized or delegated official of the 
     individual or entity. In performing the background check, the 
     Secretary shall--
       ``(1) conduct the background check before authorizing 
     billing privileges under this title to the individual or 
     entity, respectively;
       ``(2) include a search of criminal records in the 
     background check;
       ``(3) provide for procedures that ensure the background 
     check does not unreasonably delay the authorization of 
     billing privileges under this title to an eligible individual 
     or entity, respectively; and
       ``(4) establish criteria for targeted reviews when the 
     individual or entity renews participation under this title, 
     with respect to the background check of the individual or 
     entity, respectively, to detect changes in ownership, 
     bankruptcies, or felonies by the individual or entity.
       ``(b) Use of State Licensing Procedure.--The Secretary may 
     use the results of a State licensing procedure as a 
     background check under subsection (a) if the State licensing

[[Page 4677]]

      procedure meets the requirements of such subsection.
       ``(c) Attorney General Required To Provide Information.--
       ``(1) In general.--Upon request of the Secretary, the 
     Attorney General shall provide the criminal background check 
     information referred to in subsection (a)(2) to the 
     Secretary.
       ``(2) Restriction on use of disclosed information.--The 
     Secretary may only use the information disclosed under 
     subsection (a) for the purpose of carrying out the 
     Secretary's responsibilities under this title.
       ``(d) Refusal To Authorize Billing Privileges.--
       ``(1) Authority.--In addition to any other remedy available 
     to the Secretary, the Secretary may refuse to authorize 
     billing privileges under this title to an individual or 
     entity if the Secretary determines, after a background check 
     conducted under this section, that such individual or entity, 
     respectively, has a history of acts that indicate 
     authorization of billing privileges under this title to such 
     individual or entity, respectively, would be detrimental to 
     the best interests of the program or program beneficiaries. 
     Such acts may include--
       ``(A) any bankruptcy;
       ``(B) any act resulting in a civil judgment against such 
     individual or entity; or
       ``(C) any felony conviction under Federal or State law.
       ``(2) Reporting of refusal to authorize billing privileges 
     to the healthcare integrity and protection data bank 
     (hipdb).--
       ``(A) In general.--Subject to subparagraph (B), a 
     determination under paragraph (1) to refuse to authorize 
     billing privileges under this title to an individual or 
     entity as a result of a background check conducted under this 
     section shall be reported to the healthcare integrity and 
     protection data bank established under section 1128E in 
     accordance with the procedures for reporting final adverse 
     actions taken against a health care provider, supplier, or 
     practitioner under that section.
       ``(B) Exception.--Any determination described in 
     subparagraph (A) that the Secretary specifies is not 
     appropriate for inclusion in the healthcare integrity and 
     protection data bank established under section 1128E shall 
     not be reported to such data bank.''.
       (c) Denial and Suspension of Billing Privileges.--Section 
     1899C of the Social Security Act, as added by subsection (b), 
     is amended by adding at the end the following new subsection:
       ``(e) Authority To Suspend Billing Privileges or Refuse To 
     Authorize Additional Billing Privileges.--
       ``(1) In general.--The Secretary may suspend any billing 
     privilege under this title authorized for an individual or 
     entity or refuse to authorize any additional billing 
     privilege under this title to such individual or entity if--
       ``(A) such individual or entity, respectively, has an 
     outstanding overpayment due to the Secretary under this 
     title;
       ``(B) payments under this title to such individual or 
     entity, respectively, have been suspended; or
       ``(C) 100 percent of the payment claims under this title 
     for such individual or entity, respectively, are reviewed on 
     a pre-payment basis.
       ``(2) Application to restructured entities.--In the case 
     that an individual or entity is subject to a suspension or 
     refusal of billing privileges under this section, if the 
     Secretary determines that the ownership or management of a 
     new entity is under the control or management of such an 
     individual or entity subject to such a suspension or refusal, 
     the new entity shall be subject to any such applicable 
     suspension or refusal in the same manner and to the same 
     extent as the initial individual or entity involved had been 
     subject to such applicable suspension or refusal.
       ``(3) Duration of suspension.--A suspension of billing 
     privileges under this subsection, with respect to an 
     individual or entity, shall be in effect beginning on the 
     date of the Secretary's determination that the offense was 
     committed and ending not earlier than such date on which all 
     applicable overpayments and other applicable outstanding 
     debts have been paid and all applicable payment suspensions 
     have been lifted.''.
       (d) Regulations; Effective Date.--
       (1) Regulations.--Not later than one year after the date of 
     the enactment of this Act, the Secretary of Health and Human 
     Services shall promulgate such regulations as are necessary 
     to implement the amendments made by subsections (a), (b), and 
     (c).
       (2) Effective dates.--
       (A) Site inspections and background checks.--The amendments 
     made by subsections (a) and (b) shall apply to applications 
     to enroll under title XVIII of the Social Security Act 
     received by the Secretary of Health and Human Services on or 
     after the first day of the first year beginning after the 
     date of the enactment of this Act.
       (B) Denials and suspensions of billing privileges.--The 
     amendment made by subsection (c) shall apply to overpayments 
     or debts in existence on or after the date of the enactment 
     of this Act, regardless of whether the final determination, 
     with respect to such overpayment or debt, was made before, 
     on, or after such date.
       (e) Use of Medicare Integrity Program Funds.--The Secretary 
     of Health and Human Services may use funds appropriated or 
     transferred for purposes of carrying out the Medicare 
     integrity program established under section 1893 of the 
     Social Security Act (42 U.S.C. 1395ddd) to carry out the 
     provisions of sections 1899B and 1899C of that Act (as added 
     by subsections (a) and (b)).

     SEC. 1602. REGISTRATION AND BACKGROUND CHECKS OF BILLING 
                   AGENCIES AND INDIVIDUALS.

       (a) In General.--Title XVIII of the Social Security Act (42 
     U.S.C. 1395 et seq.) (as amended by section 1601) is amended 
     by adding at the end the following new section:


     ``registration and background checks of billing agencies and 
    individuals; identification numbers required for providers and 
                               suppliers

       ``Sec. 1899D.  (a) Registration.--
       ``(1) In general.--The Secretary shall establish 
     procedures, including modifying the Provider Enrollment and 
     Chain Ownership System (PECOS) administered by the Centers 
     for Medicare & Medicaid Services, to provide for the 
     registration of all applicable persons in accordance with 
     this section.
       ``(2) Required application.--Each applicable person shall 
     submit a registration application to the Secretary at such 
     time, in such manner, and accompanied by such information as 
     the Secretary may require.
       ``(3) Identification number.--If the Secretary approves an 
     application submitted under subsection (b), the Secretary 
     shall assign a unique identification number to the applicable 
     person.
       ``(4) Requirement.--Every claim for reimbursement under 
     this title that is compiled or submitted by an applicable 
     person shall contain the identification number that is 
     assigned to the applicable person pursuant to subsection (c).
       ``(5) Timely review.--The Secretary shall provide for 
     procedures that ensure the timely consideration and 
     determination regarding approval of applications under this 
     subsection.
       ``(6) Definition of applicable person.--In this section, 
     the term `applicable person' means any individual or entity 
     that compiles or submits claims for reimbursement under this 
     title to the Secretary on behalf of any individual or entity.
       ``(b) Background Checks.--
       ``(1) In General.--Except as provided in paragraph (2), the 
     Secretary shall conduct a background check on any applicable 
     person that registers under subsection (a). In performing the 
     background check, the Secretary shall--
       ``(A) conduct the background check before issuing a unique 
     identification number to the applicable person;
       ``(B) include a search of criminal records in the 
     background check;
       ``(C) provide for procedures that ensure the background 
     check does not unreasonably delay the issuance of the unique 
     identification number to an eligible applicable person; and
       ``(D) establish criteria for periodic targeted reviews with 
     respect to the background check of the applicable person.
       ``(2) Use of State Licensing Procedure.--The Secretary may 
     use the results of a State licensing procedure as a 
     background check under paragraph (1) if the State licensing 
     procedure meets the requirements of such paragraph.
       ``(3) Attorney General Required To Provide Information.--
       ``(A) In general.--Upon request of the Secretary, the 
     Attorney General shall provide the criminal background check 
     information referred to in paragraph (1)(B) to the Secretary.
       ``(B) Restriction on use of disclosed information.--The 
     Secretary may only use the information disclosed under 
     paragraph (1) for the purpose of carrying out the Secretary's 
     responsibilities under this title.
       ``(4) Refusal To Issue Unique Identification Number.--In 
     addition to any other remedy available to the Secretary, the 
     Secretary may refuse to issue a unique identification number 
     described in subsection (a)(3) to an applicable person if the 
     Secretary determines, after a background check conducted 
     under this subsection, that such person has a history of acts 
     that indicate issuance of such number under this title to 
     such person would be detrimental to the best interests of the 
     program or program beneficiaries. Such acts may include--
       ``(A) any bankruptcy;
       ``(B) any act resulting in a civil judgment against such 
     person; or
       ``(C) any felony conviction under Federal or State law.
       ``(c) Identification Numbers for Providers and Suppliers.--
     The Secretary shall establish procedures to ensure that each 
     provider of services and each supplier that submits claims 
     for reimbursement under this title to the Secretary is 
     assigned a unique identification number.''.
       (b) Permissive Exclusion.--Section 1128(b) of the Social 
     Security Act (42 U.S.C. 1320a-7(b)), as amended by section 
     6402(d) of the Patient Protection and Affordable Care Act, is 
     amended by adding at the end the following:

[[Page 4678]]

       ``(17) Fraud by applicable person.--An applicable person 
     (as defined in section 1899D(a)(6)) that the Secretary 
     determines knowingly submitted or caused to be submitted a 
     claim for reimbursement under title XVIII that the applicable 
     person knows or should know is false or fraudulent.''.
       (c) Regulations; Effective Date.--
       (1) Regulations.--Not later than one year after the date of 
     the enactment of this Act, the Secretary of Health and Human 
     Services shall promulgate such regulations as are necessary 
     to implement the amendments made by subsections (a) and (b).
       (2) Effective date.--The amendments made by subsections (a) 
     and (b) shall apply to applicable persons and other entities 
     on and after the first day of the first year beginning after 
     the date of the enactment of this Act.

     SEC. 1603. EXPANDED ACCESS TO THE HEALTHCARE INTEGRITY AND 
                   PROTECTION DATA BANK (HIPDB).

       (a) In General.--Section 1128E(d)(1) of the Social Security 
     Act (42 U.S.C. 1320a-7e(d)(1)), as amended by section 
     6403(a)(2) of the Patient Protection and Affordable Care Act, 
     is amended to read as follows:
       ``(1) Availability.--The information in the data bank 
     maintained under this section shall be available to--
       ``(A) Federal and State government agencies and health 
     plans, and any health care provider, supplier, or 
     practitioner entering an employment or contractual 
     relationship with an individual or entity who could 
     potentially be the subject of a final adverse action, where 
     the contract involves the furnishing of items or services 
     reimbursed by one or more Federal health care programs 
     (regardless of whether the individual or entity is paid by 
     the programs directly, or whether the items or services are 
     reimbursed directly or indirectly through the claims of a 
     direct provider); and
       ``(B) utilization and quality control peer review 
     organizations and accreditation entities as defined by the 
     Secretary, including but not limited to organizations 
     described in part B of this title and in section 
     1154(a)(4)(C).''.
       (b) No Fees for Use of HIPDB by Entities Contracting With 
     Medicare.--Section 1128E(d)(2) of the Social Security Act (42 
     U.S.C. 1320a-7e(d)(2)), as amended by such section 
     6403(a)(2), is amended in the first sentence by inserting 
     ``(other than with respect to requests by Federal agencies or 
     other entities, such as fiscal intermediaries and carriers, 
     acting under contract on behalf of such agencies)'' before 
     the period at the end.
       (c) Criminal Penalty for Misuse of Information.--Section 
     1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)) 
     is amended by adding at the end the following:
       ``(4) Whoever knowingly uses information maintained in the 
     healthcare integrity and protection data bank maintained in 
     accordance with section 1128E for a purpose other than a 
     purpose authorized under that section shall be imprisoned for 
     not more than three years or fined under title 18, United 
     States Code, or both.''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act.

     SEC. 1604. LIABILITY OF MEDICARE ADMINISTRATIVE CONTRACTORS 
                   FOR CLAIMS SUBMITTED BY EXCLUDED PROVIDERS.

       (a) Reimbursement to the Secretary for Amounts Paid to 
     Excluded Providers.--Section 1874A(b) of the Social Security 
     Act (42 U.S.C. 1395kk(b)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Reimbursements to secretary for amounts paid to 
     excluded providers.--The Secretary shall not enter into a 
     contract with a Medicare administrative contractor under this 
     section unless the contractor agrees to reimburse the 
     Secretary for any amounts paid by the contractor for a 
     service under this title which is furnished by an individual 
     or entity during any period for which the individual or 
     entity is excluded, pursuant to section 1128, 1128A, or 1156, 
     from participation in the health care program under this 
     title if the amounts are paid after the 60-day period 
     beginning on the date the Secretary provides notice of the 
     exclusion to the contractor, unless the payment was made as a 
     result of incorrect information provided by the Secretary or 
     the individual or entity excluded from participation has 
     concealed or altered their identity.''.
       (b) Conforming Repeal of Mandatory Payment Rule.--Section 
     1862(e) of the Social Security Act (42 U.S.C. 1395y(e)) is 
     amended--
       (1) in paragraph (1)(B), by striking ``and when the 
     person'' and all that follows through ``person)''; and
       (2) by amending paragraph (2) to read as follows:
       ``(2) No individual or entity may bill (or collect any 
     amount from) any individual for any item or service for which 
     payment is denied under paragraph (1). No individual is 
     liable for payment of any amounts billed for such an item or 
     service in violation of the preceding sentence.''.
       (c) Effective Date.--
       (1) In general.--The amendments made by this section shall 
     apply to claims for payment submitted on or after the date of 
     the enactment of this Act.
       (2) Contract modification.--The Secretary of Health and 
     Human Services shall take such steps as may be necessary to 
     modify contracts entered into, renewed, or extended prior to 
     the date of the enactment of this Act to conform such 
     contracts to the provisions of this section.

     SEC. 1605. 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)), as amended by 
     section 1301(a), is amended by striking ``entity that--'' and 
     all that follows and inserting the following: ``entity that--
       ``(i) provides the community mental health services 
     specified in paragraph (1) of section 1913(c) of the Public 
     Health Service Act;
       ``(ii) meets applicable certification or licensing 
     requirements for community mental health centers in the State 
     in which it is located;
       ``(iii) provides a significant share of its services to 
     individuals who are not eligible for benefits under this 
     title; and
       ``(iv) meets such additional standards or requirements for 
     obtaining billing privileges under this title as the 
     Secretary may specify to ensure--
       ``(I) the health and safety of beneficiaries receiving such 
     services; or
       ``(II) the furnishing of such services in an effective and 
     efficient manner.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to items and services furnished on or after the 
     first day of the sixth month that begins after the date of 
     the enactment of this Act.

     SEC. 1606. LIMITING THE DISCHARGE OF DEBTS IN BANKRUPTCY 
                   PROCEEDINGS IN CASES WHERE A HEALTH CARE 
                   PROVIDER OR A SUPPLIER ENGAGES IN FRAUDULENT 
                   ACTIVITY.

       (a) In General.--
       (1) Civil monetary penalties.--Section 1128A(a) of the 
     Social Security Act (42 U.S.C. 1320a-7a(a)) is amended by 
     adding at the end the following: ``Notwithstanding any other 
     provision of law, amounts made payable under this section are 
     not dischargeable under section 727, 944, 1141, 1228, or 1328 
     of title 11, United States Code, or any other provision of 
     such title.''.
       (2) Recovery of overpayment to providers of services under 
     part a of medicare.--Section 1815(d) of the Social Security 
     Act (42 U.S.C. 1395g(d)) is amended--
       (A) by inserting ``(1)'' after ``(d)''; and
       (B) by adding at the end the following:
       ``(2) Notwithstanding any other provision of law, amounts 
     due to the Secretary under this section are not dischargeable 
     under section 727, 944, 1141, 1228, or 1328 of title 11, 
     United States Code, or any other provision of such title if 
     the overpayment was the result of fraudulent activity, as may 
     be defined by the Secretary.''.
       (3) Recovery of overpayment of benefits under part b of 
     medicare.--Section 1833(j) of the Social Security Act (42 
     U.S.C. 1395l(j)) is amended--
       (A) by inserting ``(1)'' after ``(j)''; and
       (B) by adding at the end the following:
       ``(2) Notwithstanding any other provision of law, amounts 
     due to the Secretary under this section are not dischargeable 
     under section 727, 944, 1141, 1228, or 1328 of title 11, 
     United States Code, or any other provision of such title if 
     the overpayment was the result of fraudulent activity, as may 
     be defined by the Secretary.''.
       (4) Collection of past-due obligations arising from breach 
     of scholarship and loan contract.--Section 1892(a) of the 
     Social Security Act (42 U.S.C. 1395ccc(a)) is amended by 
     adding at the end the following:
       ``(5) Notwithstanding any other provision of law, amounts 
     due to the Secretary under this section are not dischargeable 
     under section 727, 944, 1141, 1228, or 1328 of title 11, 
     United States Code, or any other provision of such title.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to bankruptcy petitions filed after the date of 
     the enactment of this Act.

     SEC. 1607. ILLEGAL DISTRIBUTION OF A MEDICARE OR MEDICAID 
                   BENEFICIARY IDENTIFICATION OR BILLING 
                   PRIVILEGES.

       Section 1128B(b) of the Social Security Act (42 U.S.C. 
     1320a-7b(b)), as amended by section 1603, is amended by 
     adding at the end the following:
       ``(5) Whoever knowingly, intentionally, and with the intent 
     to defraud purchases, sells or distributes, or arranges for 
     the purchase, sale, or distribution of two or more Medicare 
     or Medicaid beneficiary identification numbers or billing 
     privileges under title XVIII or title XIX shall be imprisoned 
     for not more than three years or fined under title 18, United 
     States Code (or, if greater, an amount equal to the monetary 
     loss to the Federal and any State government as a result of 
     such acts), or both.''.

     SEC. 1608. TREATMENT OF CERTAIN SOCIAL SECURITY ACT CRIMES AS 
                   FEDERAL HEALTH CARE OFFENSES.

       (a) In General.--Section 24(a) of title 18, United States 
     Code, is amended--
       (1) by striking the period at the end of paragraph (2) and 
     inserting ``; or''; and
       (2) by adding at the end the following:
       ``(3) section 1128B of the Social Security Act (42 U.S.C. 
     1320a-7b).''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on the date of the enactment of this Act 
     and

[[Page 4679]]

     apply to acts committed on or after the date of the enactment 
     of this Act.

     SEC. 1609. AUTHORITY OF OFFICE OF INSPECTOR GENERAL OF THE 
                   DEPARTMENT OF HEALTH AND HUMAN SERVICES.

       (a) Authority.--Notwithstanding any other provision of law, 
     upon designation by the Inspector General of the Department 
     of Health and Human Services, any criminal investigator of 
     the Office of Inspector General of such department may, in 
     accordance with guidelines issued by the Secretary of Health 
     and Human Services and approved by the Attorney General, 
     while engaged in activities within the lawful jurisdiction of 
     such Inspector General--
       (1) obtain and execute any warrant or other process issued 
     under the authority of the United States;
       (2) make an arrest without a warrant for--
       (A) any offense against the United States committed in the 
     presence of such investigator; or
       (B) any felony offense against the United States, if such 
     investigator has reasonable cause to believe that the person 
     to be arrested has committed or is committing that felony 
     offense; and
       (3) exercise any other authority necessary to carry out the 
     authority described in paragraphs (1) and (2).
       (b) Funds.--The Office of Inspector General of the 
     Department of Health and Human Services may receive and 
     expend funds that represent the equitable share from the 
     forfeiture of property in investigations in which the Office 
     of Inspector General participated, and that are transferred 
     to the Office of Inspector General by the Department of 
     Justice, the Department of the Treasury, or the United States 
     Postal Service. Such equitable sharing funds shall be 
     deposited in a separate account and shall remain available 
     until expended.

     SEC. 1610. UNIVERSAL PRODUCT NUMBERS ON CLAIMS FORMS FOR 
                   REIMBURSEMENT UNDER THE MEDICARE PROGRAM.

       (a) UPNs on Claims Forms for Reimbursement Under the 
     Medicare Program.--
       (1) Accommodation of upns on medicare claims forms.--Not 
     later than February 1, 2011, all claims forms developed or 
     used by the Secretary of Health and Human Services for 
     reimbursement under the Medicare program under title XVIII of 
     the Social Security Act (42 U.S.C. 1395 et seq.) shall 
     accommodate the use of universal product numbers for a UPN 
     covered item.
       (2) Requirement for payment of claims.--Title XVIII of the 
     Social Security Act (42 U.S.C. 1395 et seq.), as amended by 
     sections 1601 and 1602, is amended by adding at the end the 
     following new section:


                   ``use of universal product numbers

       ``Sec. 1899E.  (a) In General.--No payment shall be made 
     under this title for any claim for reimbursement for any UPN 
     covered item unless the claim contains the universal product 
     number of the UPN covered item.
       ``(b) Definitions.--In this section:
       ``(1) UPN covered item.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the term `UPN covered item' means--
       ``(i) a covered item as that term is defined in section 
     1834(a)(13);
       ``(ii) an item described in paragraph (8) or (9) of section 
     1861(s);
       ``(iii) an item described in paragraph (5) of section 
     1861(s); and
       ``(iv) any other item for which payment is made under this 
     title that the Secretary determines to be appropriate.
       ``(B) Exclusion.--The term `UPN covered item' does not 
     include a customized item for which payment is made under 
     this title.
       ``(2) Universal product number.--The term `universal 
     product number' means a number that is--
       ``(A) affixed by the manufacturer to each individual UPN 
     covered item that uniquely identifies the item at each 
     packaging level; and
       ``(B) based on commercially acceptable identification 
     standards such as, but not limited to, standards established 
     by the Uniform Code Council-International Article Numbering 
     System or the Health Industry Business Communication 
     Council.''.
       (3) Development and implementation of procedures.--
       (A) Information included in upn.--The Secretary of Health 
     and Human Services, in consultation with manufacturers and 
     entities with appropriate expertise, shall determine the 
     relevant descriptive information appropriate for inclusion in 
     a universal product number for a UPN covered item.
       (B) Review of procedure.--From the information obtained by 
     the use of universal product numbers on claims for 
     reimbursement under the Medicare program, the Secretary of 
     Health and Human Services, in consultation with interested 
     parties, shall periodically review the UPN covered items 
     billed under the Health Care Financing Administration Common 
     Procedure Coding System and adjust such coding system to 
     ensure that functionally equivalent UPN covered items are 
     billed and reimbursed under the same codes.
       (4) Effective date.--The amendment made by paragraph (2) 
     shall apply to claims for reimbursement submitted on and 
     after February 1, 2011.
       (b) Study and Reports to Congress.--
       (1) Study.--The Secretary of Health and Human Services 
     shall conduct a study on the results of the implementation of 
     the provisions in paragraphs (1) and (3) of subsection (a) 
     and the amendment to the Social Security Act in paragraph (2) 
     of such subsection.
       (2) Reports.--
       (A) Progress report.--Not later than 6 months after the 
     date of the enactment of this Act, the Secretary of Health 
     and Human Services shall submit to Congress a report that 
     contains a detailed description of the progress of the 
     matters studied pursuant to paragraph (1).
       (B) Implementation.--Not later than 18 months after the 
     date of the enactment of this Act, and annually thereafter 
     for 3 years, the Secretary of Health and Human Services shall 
     submit to Congress a report that contains a detailed 
     description of the results of the study conducted pursuant to 
     paragraph (1), together with the Secretary's recommendations 
     regarding the use of universal product numbers and the use of 
     data obtained from the use of such numbers.
       (c) Definitions.--In this section:
       (1) UPN covered item.--The term ``UPN covered item'' has 
     the meaning given such term in section 1899E(b)(1) of the 
     Social Security Act (as added by subsection (a)(2)).
       (2) Universal product number.--The term ``universal product 
     number'' has the meaning given such term in section 
     1899E(b)(2) of the Social Security Act (as added by 
     subsection (a)(2)).
       (d) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary for the 
     purpose of carrying out the provisions in paragraphs (1) and 
     (3) of subsection (a), subsection (b), and section 1899E of 
     the Social Security Act (as added by subsection (a)(2)).

     SEC. 1611. USE OF TECHNOLOGY FOR REAL-TIME DATA REVIEW.

       Part A of title XI of the Social Security Act (42 U.S.C. 
     1395 et seq.), as amended by section 6703(b) of the Patient 
     Protection and Affordable Care Act, is amended by adding at 
     the end the following new section:

     ``SEC. 1150C. USE OF TECHNOLOGY FOR REAL TIME DATA REVIEW.

       ``(a) In General.--The Secretary shall establish procedures 
     for the use of technology (similar to that used with respect 
     to the analysis of credit card charging patterns) to provide 
     real-time data analysis of claims for payment under the 
     Medicare, Medicaid, and SCHIP programs under title XVIII, 
     XIX, and XXI to identify and investigate unusual billing or 
     order practices under such programs that could indicate fraud 
     or abuse.
       ``(b) Competitive Bidding.--The procedures established 
     under subsection (a) shall ensure that the implementation of 
     such technology is conducted through a competitive bidding 
     process.
       ``(c) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary, not to exceed $50,000,000 for each of 
     fiscal years 2010 through 2014.
       ``(d) Report to Congress.--The Secretary shall submit to 
     Congress an annual report on the effectiveness of activities 
     conducted under this section, including a description of any 
     savings to the programs referred to in subsection (a) as a 
     result of such activities and the overall administrative cost 
     of such activities and a determination as to the amount of 
     funding needed to carry out this section for subsequent 
     fiscal years, together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.''.

     SEC. 1612. COMPREHENSIVE SANCTIONS DATABASE AND ACCESS TO 
                   CLAIMS AND PAYMENT DATABASES.

       (a) Comprehensive Sanctions Database.--The Secretary of 
     Health and Human Services (in this section referred to as the 
     ``Secretary'') shall establish a comprehensive sanctions 
     database on sanctions imposed on providers of services, 
     suppliers, and related entities. Such database shall be 
     overseen by the Inspector General of the Department of Health 
     and Human Services and shall be linked to related databases 
     maintained by State licensure boards and by Federal or State 
     law enforcement agencies.
       (b) Access to Claims and Payment Databases.--The Secretary 
     shall ensure that the Inspector General of the Department of 
     Health and Human Services and Federal law enforcement 
     agencies have direct access to all claims and payment 
     databases of the Secretary under the Medicare or Medicaid 
     programs.
       (c) Civil Money Penalties for Submission of Erroneous 
     Information.--In the case of a provider of services, 
     supplier, or other entity that knowingly submits erroneous 
     information that serves as a basis for payment of any entity 
     under the Medicare or Medicaid program, the Secretary may 
     impose a civil money penalty of not to exceed $50,000 for 
     each such erroneous submission. A civil money penalty under 
     this subsection shall be imposed and collected in the same 
     manner as a civil money penalty under subsection (a) of 
     section 1128A of the Social Security Act is imposed and 
     collected under that section.
                                 ______
                                 
  SA 3561. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of

[[Page 4680]]

the concurrent resolution on the budget for fiscal year 2010 (S. Con. 
Res. 13); which was ordered to lie on the table; as follows:

       At the end of subtitle B of title II, add the following:

     SEC. 2304. NONDISCRIMINATION ON ABORTION AND RESPECT FOR 
                   RIGHTS OF CONSCIENCE.

       (a) Nondiscrimination.--A Federal agency or program, and 
     any State or local government, or health care entity that 
     receives Federal financial assistance under the Patient 
     Protection and Affordable Care Act (or an amendment made by 
     such Act), shall not--
       (1) subject any individual or institutional health care 
     entity to discrimination; or
       (2) require any health care entity that is established or 
     regulated under the Patient Protection and Affordable Care 
     Act (or an amendment made by such Act) to subject any 
     individual or institutional health care entity to 
     discrimination,
     on the basis that the health care entity does not provide, 
     pay for, provide coverage of, or refer for abortions.
       (b) Definition.--In this section, the term ``health care 
     entity'' includes an individual physician or other health 
     care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, a plan sponsor, a health insurance issuer, a 
     qualified health plan or issuer offering such a plan, or any 
     other kind of health care facility, organization, or plan.
       (c) Administration.--The Office for Civil Rights of the 
     Department of Health and Human Services is designated to 
     receive complaints of discrimination based on this section, 
     and coordinate the investigation of such complaints.
                                 ______
                                 
  SA 3562. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of section 1405, add the following:
       (e) Nonapplication to Class I Devices.--Paragraph (2) of 
     section 4191(b) of the Internal Revenue Code of 1986, as 
     added by subsection (a), is amended by redesignating 
     subparagraphs (A) through (D) as subparagraphs (B) through 
     (E), respectively, and by inserting before subparagraph (B) 
     (as so redesignated) the following new subparagraph:
       ``(A) devices classified in class I under section 513 of 
     such Act,''.
                                 ______
                                 
  SA 3563. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle F of title I, add the following:

     SEC. 1502. REPEAL OF PERSONAL RESPONSIBILITY EDUCATION 
                   PROGRAM.

       Section 513 of the Social Security Act, as added by section 
     2953 and amended by section 10201(h) the Patient Protection 
     and Affordable Care Act, is repealed.
                                 ______
                                 
  SA 3564. Mr. GRASSLEY (for himself and Mr. Roberts) submitted an 
amendment intended to be proposed by him to the bill H.R. 4872, to 
provide for reconciliation pursuant to Title II of the concurrent 
resolution on the budget for fiscal year 2010 (S. Con. Res. 13); as 
follows:

       At the end of subtitle A of title I, insert the following:

     SEC. 1006. PARTICIPATION OF PRESIDENT, VICE PRESIDENT, 
                   MEMBERS OF CONGRESS, POLITICAL APPOINTEES, AND 
                   CONGRESSIONAL STAFF IN THE EXCHANGE.

       (a) In General.--Section 1312(d)(3)(D) of the Patient 
     Protection and Affordable Care Act is amended to read as 
     follows:
       ``(D) President, vice president, members of congress, 
     political appointees, and congressional staff in the 
     exchange.--
       ``(i) In general.--Notwithstanding chapter 89 of title 5, 
     United States Code, or any provision of this title--

       ``(I) the President, Vice President, each Member of 
     Congress, each political appointee, and each Congressional 
     employee shall be treated as a qualified individual entitled 
     to the right under this paragraph to enroll in a qualified 
     health plan in the individual market offered through an 
     Exchange in the State in which the individual resides; and
       ``(II) any employer contribution under such chapter on 
     behalf of the President, Vice President, any Member of 
     Congress, any political appointee, and any Congressional 
     employee may be paid only to the issuer of a qualified health 
     plan in which the individual enrolled in through such 
     Exchange and not to the issuer of a plan offered through the 
     Federal employees health benefit program under such chapter.

       ``(ii) Payments by federal government.--The Secretary, in 
     consultation with the Director of the Office of Personnel 
     Management, shall establish procedures under which--

       ``(I) the employer contributions under such chapter on 
     behalf of the President, Vice President, and each political 
     appointee are determined and actuarially adjusted for age; 
     and
       ``(II) the employer contributions may be made directly to 
     an Exchange for payment to an issuer.

       ``(iii) Political appointee.--In this subparagraph, the 
     term `political appointee' means any individual who--

       ``(I) is employed in a position described under sections 
     5312 through 5316 of title 5, United States Code, (relating 
     to the Executive Schedule);
       ``(II) is a limited term appointee, limited emergency 
     appointee, or noncareer appointee in the Senior Executive 
     Service, as defined under paragraphs (5), (6), and (7), 
     respectively, of section 3132(a) of title 5, United States 
     Code; or
       ``(III) is employed in a position in the executive branch 
     of the Government of a confidential or policy-determining 
     character under schedule C of subpart C of part 213 of title 
     5 of the Code of Federal Regulations.

       ``(iv) Congressional employee.--In this subparagraph, the 
     term `Congressional employee' means an employee whose pay is 
     disbursed by the Secretary of the Senate or the Clerk of the 
     House of Representatives.''.
       (b) Effective Date.--The amendment made by this section 
     shall take effect as if included in the Patient Protection 
     and Affordable Care Act.
                                 ______
                                 
  SA 3565. Mr. INHOFE submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       On page 99, between lines 9 and 10, insert the following:
       (e) Exclusion of Assistive Devices for Persons With 
     Disabilities.--
       (1) In general.--For purposes of section 4191(b)(1) of the 
     Internal Revenue Code of 1986, as added by subsection (a), 
     the term ``taxable medical device'' shall not include any 
     device which is primarily designed to assist persons with 
     disabilities with tasks of daily life.
       (2) Expansion of affordability exception to individual 
     mandate.--Section 5000A(e)(1)(A) 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 by striking ``8 percent'' and 
     inserting ``5 percent''.
       (3) Application of provision.--The amendment made by 
     paragraph (2) shall apply as if included in the Patient 
     Protection and Affordable Care Act.
                                 ______
                                 
  SA 3566. Mr. COBURN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle F of title I, insert the following:

     SEC. ___. INCREASED TRANSPARENCY.

       (a) Scoring and Summary.--It shall not be in order in the 
     Senate or the House of Representatives to vote on final 
     passage on a bill, resolution, or conference report unless a 
     final Congressional Budget Office score and Congressional 
     Research Service summary report on policy changes in the 
     bill, resolution, or conference report has been posted online 
     on the public website of the body 72 hours before such final 
     vote.
       (b) Additional Requirements.--The information required to 
     be posted by subsection (a) shall also include--
       (1) an affidavit that the policy summary of the 
     Congressional Research Service adequately reflects the 
     measure signed by the Majority and Minority Leaders; and
       (2) signed affidavits from every member of the body 
     attesting that they have read the measure.
       (c) Waiver and Appeal.--
       (1) Waiver.--This section may be waived or suspended in the 
     Senate or House of Representatives only by an affirmative 
     vote of \3/5\ of the members, duly chosen and sworn.
       (2) Appeal.--An affirmative vote of \3/5\ of the members of 
     the Senate or House of Representatives, duly chosen and 
     sworn, shall be required to sustain an appeal of the ruling 
     of the Chair on a point of order raised under this 
     subsection.
       (d) Public Availability of Amendments.--Each amendment 
     offered in the Senate or House of Representatives shall to be 
     posted online on the public website of the body as soon as 
     practicable after the amendment is offered.
                                 ______
                                 
  SA 3567. Mr. GREGG (for himself and Mr. Coburn) proposed an amendment 
to the bill H.R. 4872, to provide for reconciliation pursuant to Title 
II of the

[[Page 4681]]

concurrent resolution on the budget for fiscal year 2010 (S. Con. Res. 
13); as follows:

       At the end of subtitle B of title I, add the following:

     SEC. ___. PREVENTING THE IMPLEMENTATION OF NEW ENTITLEMENTS 
                   THAT WOULD RAID MEDICARE.

       (a) Ban on New Spending Taking Effect.--
       (1) In general.--Notwithstanding any other provision of 
     law, the Secretary of the Treasury and the Secretary of 
     Health and Human Service are prohibited from implementing any 
     spending increase or revenue reduction provision in either 
     the Patient Protection and Affordable Care Act or this Act 
     (referred to in this section as the ``Health Care Acts'') 
     unless both the Director of the Office of Management and 
     Budget (referred to in this section as ``OMB'') and the Chief 
     Actuary of the Centers for Medicare and Medicaid Services 
     Office of the Actuary (referred to in this section as`` CMS 
     OACT'') certify that they project that all of the projected 
     Federal spending increases and revenue reductions resulting 
     from the Health Care Acts will be offset by projected gross 
     savings from the Health Care Acts.
       (2) Calculations.--For purposes of this section, projected 
     gross savings shall--
       (A) include gross reductions in Federal spending and gross 
     increases in revenues made by the Health Care Acts; and
       (B) exclude any projected gross savings or other offsets 
     directly resulting from changes to Medicare made by the 
     Health Care Acts.
       (b) Limit on Future Spending.--For the purpose of carrying 
     out this section and upon the enactment of this Act, CMS OACT 
     and the OMB shall--
       (1) certify whether all of the projected Federal spending 
     increases and revenue reductions resulting from the Health 
     Care Acts, starting with fiscal year 2014 and for the 
     following 9 fiscal years, are fully offset by projected gross 
     savings resulting from the Health Care Acts (as calculated 
     under subsection (a)(2)); and
       (2) provide detailed estimates of such spending increases, 
     revenue reductions, and gross savings, year by year, program 
     by program and provision by provision.
                                 ______
                                 
  SA 3568. Mr. BENNETT (for himself, Mr. Wicker, Mr. Brownback, Mr. 
Hatch, Mr. Roberts, Mr. Inhofe, Mr. Cornyn, and Mr. Enzi) submitted an 
amendment intended to be proposed by him to the bill H.R. 4872, to 
provide for reconciliation pursuant to Title II of the concurrent 
resolution on the budget for fiscal year 2010 (S. Con. Res. 13); which 
was ordered to lie on the table; as follows:

       At the end of subtitle B of title I, add the following:

     SEC. ___. RIGHT OF THE PEOPLE OF THE DISTRICT OF COLUMBIA TO 
                   DEFINE MARRIAGE.

       (a) Findings.--Congress finds that--
       (1) a broad coalition of residents of the District of 
     Columbia petitioned for an initiative in accordance with the 
     District of Columbia Home Rule Act to establish that ``only 
     marriage between a man and a woman is valid or recognized in 
     the District of Columbia'';
       (2) this petition anticipated the Council of the District 
     of Columbia's passage of an Act legalizing same-sex marriage;
       (3) the unelected District of Columbia Board of Elections 
     and Ethics and the unelected District of Columbia Superior 
     Court thwarted the residents' initiative effort to define 
     marriage democratically, holding that the initiative amounted 
     to discrimination prohibited by the District of Columbia 
     Human Rights Act; and
       (4) the definition of marriage affects every person and 
     should be debated openly and democratically.
       (b) Referendum or Initiative Requirement.--Notwithstanding 
     any other provision of law, including the District of 
     Columbia Human Rights Act, the government of the District of 
     Columbia shall immediately suspend the issuance of marriage 
     licenses to any couple of the same sex until the people of 
     the District of Columbia have the opportunity to hold a 
     referendum or initiative on the question of whether the 
     District of Columbia should issue same-sex marriage licenses.
                                 ______
                                 
  SA 3569. Mr. GRASSLEY submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title I, insert the following:

     SEC. __. REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC 
                   ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE 
                   SCHEDULE.

       Effective as if included in the enactment of the Patient 
     Protection and Affordable Care Act, subparagraph (H) of 
     section 1848(e)(1) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)), as added by section 3102(b) of the Patient 
     Protection and Affordable Care Act, is amended to read as 
     follows:
       ``(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 \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.
       ``(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 \1/4\ 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.
       ``(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).

     In conducting such analysis, the Secretary shall not take 
     into account any data that is not actual or survey data.
       ``(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 
     occupancy costs only and making weighting changes in other 
     categories as appropriate;
       ``(II) ensuring that office expenses that do not vary from 
     region to region be included in the `other' office expense 
     category; and
       ``(III) 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.
       ``(vi) Special rule.--If the Secretary does not complete 
     the analysis described in clause (iv) and make any 
     adjustments the Secretary determines appropriate for 2012 or 
     a subsequent year under clause (v), the Secretary shall apply 
     clause (ii) for services furnished during 2012 or a 
     subsequent year in the same manner as such clause applied for 
     services furnished during 2011.''.

     SEC. __. ELIMINATION OF SWEETHEART DEAL THAT INCREASES 
                   MEDICARE REIMBURSEMENT JUST FOR FRONTIER 
                   STATES.

       Effective as if included in the enactment of the Patient 
     Protection and Affordable Care Act, section 10324 of such Act 
     (and the amendments made by such section) is repealed.
                                 ______
                                 
  SA 3570. Mr. McCAIN (for himself, Mr. Burr, and Mr. Coburn) proposed 
an amendment to the bill H.R. 4872, to provide for reconciliation 
pursuant to Title II of the concurrent resolution on the budget for 
fiscal year 2010 (S. Con. Res. 13); as follows:

       At the end of subtitle F of title I, add the following:

     SEC. 1502. ELIMINATION OF SWEETHEART DEALS.

       (a) Repeals.--Effective as if included in the enactment of 
     the Patient Protection and Affordable Care Act, the following 
     provisions are repealed:
       (1) Sweetheart deal to provide tennessee with medicaid dsh 
     funds.--Clause (v) of section 1923(f)(6)(A) of the Social 
     Security Act (42 U.S.C. 1396r-4(f)(6)(A)), as added by 
     section 1203(b) of this Act.
       (2) Sweetheart deal to provide hawaii with medicaid dsh 
     funds.--Clause (iii) of section 1923(f)(6)(B) of the Social 
     Security Act (42 U.S.C. 1396r-4(f)(6)(B)), as added by 
     section 10201(e)(1)(A) of the Patient Protection and 
     Affordable Care Act.

[[Page 4682]]

       (3) Sweetheart deal to provide louisiana with a special 
     increased medicaid fmap.--Subsection (aa) of section 1905 of 
     the Social Security Act, as added by section 2006 of the 
     Patient Protection and Affordable Care Act.
       (4) Sweetheart deal that increases medicare reimbursement 
     just for frontier states.--Section 10324 of the Patient 
     Protection and Affordable Care Act (and the amendments made 
     by such section).
       (5) Sweetheart deal granting medicare coverage for 
     individuals exposed to environmental hazards in libby, 
     montana.--Section 10323 of the Patient Protection and 
     Affordable Care Act (and the amendments made by such 
     section).
       (6) Sweetheart deal for a hospital in connecticut.--Section 
     10502 of the Patient Protection and Affordable Care Act.
       (b) Elimination of Sweetheart Deal That Reclassifies 
     Hospitals in Michigan and Connecticut to Increase Their 
     Medicare Reimbursement.--Section 3137(a) of the Patient 
     Protection and Affordable Care Act, as amended by section 
     10317 of such Act, is amended--
       (1) in paragraph (2)--
       (A) by striking ``fiscal year 2010'' and all that follows 
     through ``for purposes of implementation of the amendment'' 
     and inserting ``fiscal year 2010.--For purposes of 
     implementation of the amendment''; and
       (B) by striking subparagraph (B); and
       (2) by striking paragraph (3).
                                 ______
                                 
  SA 3571. Ms. COLLINS submitted an amendment intended to be proposed 
by her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle F of title I, insert the following:

     SEC. 1__. SPECIAL RULE FOR INDIVIDUALS AGE 30 AND OVER NOT 
                   ELIGIBLE FOR EXCHANGE CREDITS AND REDUCTIONS.

       Section 1302(e) of the Patient Protection and Affordability 
     Act is amended--
       (1) by redesignating paragraph (3) as paragraph (4); and
       (2) by inserting after paragraph (2), the following:
       ``(3) Special rule for individuals age 30 and over not 
     eligible for exchange credits and reductions.--
       ``(A) In general.--Subject to subparagraph (B), an 
     individual who has attained at least the age of 30 before the 
     beginning of a plan year shall be treated as an individual 
     described in paragraph (2) if the individual is not eligible 
     for the plan year for the premium tax credit under section 
     36B of the Internal Revenue Code of 1986 or the cost-sharing 
     reductions under section 1402 with respect to enrollment in a 
     qualified health plan offered through an Exchange. The 
     preceding sentence shall not apply to an individual if the 
     individual is not eligible for such credit or reductions 
     because the individual is eligible to enroll in minimum 
     essential coverage consisting of coverage under a government 
     sponsored program described in section 5000A(f)(1)(A).
       ``(B) Requirements.--Subparagraph (A) shall only apply to 
     an individual if the individual elects the application of 
     this paragraph and such election provides that--
       ``(i) the individual acknowledges that coverage under the 
     catastrophic plan is the lowest coverage available, 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 that these cost-sharing expenses could involve 
     significant financial risk for the individual; and
       ``(ii) the individual agrees that--

       ``(I) the individual will not change such coverage until 
     the next applicable annual or special enrollment period under 
     section 1311(c)(5); and
       ``(II) if the individual elects to change such coverage at 
     the time of such enrollment period, the individual may only 
     enroll in the bronze level of coverage.

       ``(4) State authority.--In accordance with section 1321(d), 
     a State may impose additional requirements or conditions for 
     catastrophic plans described in this subsection to the extent 
     such requirements or conditions are not inconsistent with the 
     requirements under this subsection.''.
                                 ______
                                 
  SA 3572. Ms. COLLINS submitted an amendment intended to be proposed 
by her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title I, add the following:

     SEC. __. ASSESSMENT OF MEDICARE COST-INTENSIVE DISEASES AND 
                   CONDITIONS.

       (a) Initial Assessment.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     conduct an assessment of the diseases and conditions that are 
     the most cost-intensive for the Medicare program under title 
     XVIII of the Social Security Act and, to the extent possible, 
     assess the diseases and conditions that could become cost-
     intensive for the Medicare program in the future.
       (2) Report.--Not later than January 1, 2011, the Secretary 
     shall transmit a report to the Committees on Energy and 
     Commerce, Ways and Means, and Appropriations of the House of 
     Representatives and the Committees on Health, Education, 
     Labor and Pensions, Finance, and Appropriations of the Senate 
     on the assessment conducted under paragraph (1). Such report 
     shall--
       (A) include the assessment of current and future trends of 
     cost-intensive diseases and conditions described in such 
     paragraph;
       (B) address whether current research priorities are 
     appropriately addressing current and future cost-intensive 
     conditions so identified;
       (C) include the input of relevant research agencies, 
     including the National Institutes of Health, the Agency for 
     Healthcare Research and Quality, and the Food and Drug 
     Administration; and
       (D) include recommendations concerning research in the 
     Department of Health and Human Services that should be funded 
     to improve the prevention, treatment, or cure of such cost-
     intensive diseases and conditions.
       (b) Updates of Assessment.--Not later than January 1, 2013, 
     and biennially thereafter, the Secretary shall--
       (1) review and update the assessment and recommendations 
     described in subsection (a)(1); and
       (2) submit a report described in subsection (a)(2) to the 
     Committees specified in subsection (a)(2) on such updated 
     assessment and recommendations.
       (c) CMS Medicare Cost-Intensive Research Fund.--
       (1) In general.--There is established in the Treasury of 
     the United States a fund to be known as the ``CMS Medicare 
     Cost-Intensive Research Fund'', in this subsection referred 
     to as the ``Fund''. The Administrator of the Centers for 
     Medicare & Medicaid Services shall administer the Fund. The 
     Fund shall consist of such amounts as may be appropriated or 
     credited to such Fund for the purposes described in paragraph 
     (2). The Administrator shall not transfer appropriations to 
     or from other relevant research agencies, including the 
     National Institutes of Health, the Agency for Healthcare 
     Research and Quality, and the Food and Drug Administration.
       (2) Purposes of fund.--From amounts in the Fund, the 
     Administrator of the Centers for Medicare & Medicaid Services 
     shall make available research grants, contracts, and other 
     funding mechanisms to facilitate research into the 
     prevention, treatment, or cure of cost-intensive diseases and 
     conditions under the Medicare program as recommended by the 
     reports under this section.
                                 ______
                                 
  SA 3573. Ms. COLLINS submitted an amendment intended to be proposed 
by her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title I, add the following:

     SEC. __. IMPROVING CARE PLANNING FOR MEDICARE HOME HEALTH 
                   SERVICES.

       (a) 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--
       (1) by inserting ``(as those terms are defined in section 
     1861(aa)(5))'' after ``clinical nurse specialist''; and
       (2) by inserting ``, or in the case of services described 
     in subparagraph (C), a physician, or a nurse practitioner or 
     clinical nurse specialist who is working in collaboration 
     with a 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 a physician'' after 
     ``collaboration with a physician''.
       (b) Conforming Amendments.--(1) Section 1814(a) of the 
     Social Security Act (42 U.S.C. 1395f(a)), as amended by 
     sections 3108(a)(2) and section 6407 of the Patient 
     Protection and Affordable Care Act, is amended--
       (A) in paragraph (2)(C), by inserting ``, a nurse 
     practitioner, a clinical nurse specialist, a certified nurse-
     midwife, or a physician assistant (as the case may be)'' 
     after ``physician'' each place it appears;
       (B) in the second sentence, by inserting ``certified nurse-
     midwife,'' after ``clinical nurse specialist,'';
       (C) in the third sentence--
       (i) by striking ``physician certification'' and inserting 
     ``certification'';
       (ii) by inserting ``(or on January 1, 2008, in the case of 
     regulations to implement the amendments made by section 3115 
     of the Patient Protection and Affordable Care Act)'' after 
     ``1981''; and
       (iii) by striking ``a physician who'' and inserting ``a 
     physician, nurse practitioner,

[[Page 4683]]

     clinical nurse specialist, certified nurse-midwife, or 
     physician assistant who''; and
       (D) in the fourth sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, certified nurse-
     midwife, or physician assistant'' after ``physician''.
       (2) Section 1835(a) of the Social Security Act (42 U.S.C. 
     1395n(a)), as amended by section 6405 of the Patient 
     Protection and Affordable Care Act, is amended--
       (A) in paragraph (2)--
       (i) in the matter preceding subparagraph (A), by striking 
     ``or an eligible professional under section 1848(k)(3)(B)'' 
     and inserting ``, an eligible professional under section 
     1848(k)(3)(B), or a nurse practitioner or clinical nurse 
     specialist (as those terms are defined in 1861(aa)(5)) who is 
     working in collaboration with a physician enrolled under 
     section 1866(j) or such an eligible professional 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 a physician so enrolled or such an 
     eligible professional''; and
       (ii) in each of clauses (ii) and (iii) of subparagraph (A) 
     by inserting ``, a nurse practitioner, a clinical nurse 
     specialist, a certified nurse-midwife, or a physician 
     assistant (as the case may be)'' after ``physician'';
       (B) in the third sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, certified nurse-
     midwife, or physician assistant (as the case may be)'' after 
     physician;
       (C) in the fourth sentence--
       (i) by striking ``physician certification'' and inserting 
     ``certification'';
       (ii) by inserting ``(or on January 1, 2008, in the case of 
     regulations to implement the amendments made by section 3115 
     of the Patient Protection and Affordable Care Act)'' after 
     ``1981''; and
       (iii) by striking ``a physician who'' and inserting ``a 
     physician, nurse practitioner, clinical nurse specialist, 
     certified nurse-midwife, or physician assistant who''; and
       (D) in the fifth sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, certified nurse-
     midwife, or physician assistant'' after ``physician''.
       (3) Section 1861 of the Social Security Act (42 U.S.C. 
     1395x) is amended--
       (A) in subsection (m)--
       (i) in the matter preceding paragraph (1)--
       (I) by inserting ``a nurse practitioner or a clinical nurse 
     specialist (as those terms are defined in subsection 
     (aa)(5)), a certified nurse-midwife (as defined in section 
     1861(gg)), or a physician assistant (as defined in subsection 
     (aa)(5))'' after ``physician'' the first place it appears; 
     and
       (II) by inserting ``a nurse practitioner, a clinical nurse 
     specialist, a certified nurse-midwife, or a physician 
     assistant'' after ``physician'' the second place it appears; 
     and
       (ii) in paragraph (3), by inserting ``a nurse practitioner, 
     a clinical nurse specialist, a certified nurse-midwife, or a 
     physician assistant'' after ``physician''; and
       (B) in subsection (o)(2)--
       (i) by inserting ``, nurse practitioners or clinical nurse 
     specialists (as those terms are defined in subsection 
     (aa)(5)), certified nurse-midwives (as defined in section 
     1861(gg)), or physician assistants (as defined in subsection 
     (aa)(5))'' after ``physicians''; and
       (ii) by inserting ``, nurse practitioner, clinical nurse 
     specialist, certified nurse-midwife, physician assistant,'' 
     after ``physician''.
       (4) Section 1895 of the Social Security Act (42 U.S.C. 
     1395fff) is amended--
       (A) in subsection (c)(1), by inserting ``, the nurse 
     practitioner or clinical nurse specialist (as those terms are 
     defined in section 1861(aa)(5)), the certified nurse-midwife 
     (as defined in section 1861(gg)), or the physician assistant 
     (as defined in section 1861(aa)(5)),'' after ``physician''; 
     and
       (B) in subsection (e)--
       (i) in paragraph (1)(A), by inserting ``, a nurse 
     practitioner or clinical nurse specialist (as those terms are 
     defined in section 1861(aa)(5)), a certified nurse-midwife 
     (as defined in section 1861(gg)), or a physician assistant 
     (as defined in section 1861(aa)(5))'' after ``physician''; 
     and
       (ii) in paragraph (2)--
       (I) in the heading, by striking ``Physician certification'' 
     and inserting ``Rule of construction regarding requirement 
     for certification''; and
       (II) by striking ``physician''.
       (c) Requirement of Face-to-Face Encounter.--
       (1) Part a.--Section 1814(a)(2)(C) of the Social Security 
     Act, as amended by subsection (b) and section 6407(a) of the 
     Patient Protection and Affordable Care Act, is further 
     amended by striking ``, and, in the case of a certification 
     made by a physician'' and all that follows through ``face-to-
     face encounter'' and inserting ``, and, in the case of a 
     certification made by a physician after January 1, 2010, or 
     by a nurse practitioner, clinical nurse specialist, certified 
     nurse-midwife, or physician assistant (as the case may be) 
     after January 1, 2011, prior to making such certification the 
     physician, nurse practitioner, clinical nurse specialist, 
     certified nurse-midwife, or physician assistant must document 
     that the physician, nurse practitioner, clinical nurse 
     specialist, certified nurse-midwife, or physician assistant 
     himself or herself has had a face-to-face encounter''.
       (2) Part b.--Section 1835(a)(2)(A)(iv) of the Social 
     Security Act, as added by section 6407(a) of the Patient 
     Protection and Affordable Care Act, is amended by striking 
     ``after January 1, 2010'' and all that follows through 
     ``face-to-face encounter'' and inserting ``made by a 
     physician after January 1, 2010, or by a nurse practitioner, 
     clinical nurse specialist, certified nurse-midwife, or 
     physician assistant (as the case may be) after January 1, 
     2011, prior to making such certification the physician, nurse 
     practitioner, clinical nurse specialist, certified nurse-
     midwife, or physician assistant must document that the 
     physician, nurse practitioner, clinical nurse specialist, 
     certified nurse-midwife, or physician assistant has had a 
     face-to-face encounter''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.
                                 ______
                                 
  SA 3574. Mr. LeMIEUX submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       On page 123, strike line 9 and all that follows through 
     line 2 on page 144.
                                 ______
                                 
  SA 3575. Mr. LeMIEUX submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       On page 114, strike line 3 and all that follows through 
     line 2 on page 144.
                                 ______
                                 
  SA 3576. Mr. McCAIN submitted an amendment intended to be proposed by 
him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle F of title I, add the following:

     SEC. 1502. JUDICIAL REVIEW.

       (a) Challenge by Members of Congress.--Any Member of 
     Congress may bring an action for declaratory or injunctive 
     relief to challenge the constitutionality of any provision of 
     this Act, any amendment made by this Act, any provision of 
     the Patient Protection and Affordable Care Act, or any 
     amendment made by that Act, which may be filed in any United 
     States district court of appropriate jurisdiction.
       (b) Intervention by Members of Congress.--In any action in 
     which the constitutionality of any provision of this Act, any 
     amendment made by this Act, any provision of the Patient 
     Protection and Affordable Care Act, or any amendment made by 
     that Act is raised, any member of the House of 
     Representatives (including a Delegate or Resident 
     Commissioner to the Congress) or Senate shall have the right 
     to intervene either in support of or opposition to the 
     position of a party to the case regarding the 
     constitutionality of the provision or amendment. To avoid 
     duplication of efforts and reduce the burdens placed on the 
     parties to the action, the court in any such action may make 
     such orders as it considers necessary, including orders to 
     require intervenors taking similar positions to file joint 
     papers or to be represented by a single attorney at oral 
     argument.
                                 ______
                                 
  SA 3577. Mr. ROBERTS submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title I, insert the following:

     SEC. __. PROTECTING MEDICARE BENEFICIARY ACCESS TO HOSPITAL 
                   CARE IN RURAL AREAS FROM RECOMMENDATIONS BY THE 
                   INDEPENDENT PAYMENT ADVISORY BOARD.

       (a) In General.--Section 1899A(c)(2)(A) of the Social 
     Security Act, as added by section 3403 of the Patient 
     Protection and Affordable Care Act and amended by section 
     10320 of such Act, is amended by adding at the end the 
     following new clause:
       ``(vii) The proposal shall not include any recommendation 
     that would reduce payment rates for items and services 
     furnished by a critical access hospital (as defined in 
     section 1861(mm)(1)).''.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act, is amended by striking 
     ``8 percent'' and inserting ``5 percent''.
                                 ______
                                 
  SA 3578. Mr. ROBERTS submitted an amendment intended to be proposed 
by

[[Page 4684]]

him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle B of title I, insert the following:

     SEC. __. PROTECTING MEDICARE BENEFICIARY ACCESS TO HEALTH 
                   CARE FROM RECOMMENDATIONS BY THE INDEPENDENT 
                   PAYMENT ADVISORY BOARD.

       (a) In General.--Section 1899A(c)(2)(A) of the Social 
     Security Act, as added by section 3403 of the Patient 
     Protection and Affordable Care Act and amended by section 
     10320 of such Act, is amended by adding at the end the 
     following new clause:
       ``(vii) The proposal shall not include any recommendation 
     that would result in reduced beneficiary access to care.''.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) of the Internal Revenue Code 
     of 1986, as added by section 1501(b) of the Patient 
     Protection and Affordable Care Act, is amended by striking 
     ``8 percent'' and inserting ``5 percent''.
                                 ______
                                 
  SA 3579. Mr. ROBERTS (for himself, Mr. Inhofe, and Mr. Brown of 
Massachusetts) submitted an amendment intended to be proposed by him to 
the bill H.R. 4872, to provide for reconciliation pursuant to Title II 
of the concurrent resolution on the budget for fiscal year 2010 (S. 
Con. Res. 13); which was ordered to lie on the table; as follows:

       Strike section 1405 and insert the following:

     SEC. 1405. REPEAL OF MEDICAL DEVICE FEE.

       (a) In General.--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 the enactment of that 
     Act.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) 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 by striking ``8 percent'' and 
     inserting ``5 percent''.
       (c) Application of Provision.--The amendment made by 
     subsection (b) shall apply as if included in the Patient 
     Protection and Affordable Care Act.
                                 ______
                                 
  SA 3580. Mr. ROBERTS submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       Strike section 1403 and insert the following:

     SECTION 1403. REPEAL OF LIMITATION ON HEALTH FLEXIBLE 
                   SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS.

       (a) In General.--Sections 9005 and 10902 of the Patient 
     Protection and Affordable Care Act are hereby repealed 
     effective as of the date of the enactment of such Act and any 
     provisions of law amended by such sections are amended to 
     read as such provisions would read if such sections had never 
     been enacted.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) 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 by striking ``8 percent'' and 
     inserting ``5 percent''.
       (c) Application of Provision.--The amendment made by 
     subsection (b) shall apply as if included in the Patient 
     Protection and Affordable Care Act.
                                 ______
                                 
  SA 3581. Mr. ROBERTS submitted an amendment intended to be proposed 
by him to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle E of title I, insert the following:

     SECTION --. REPEAL OF LIMITATION ON DEDUCTIONS FOR OVER-THE-
                   COUNTER MEDICINE.

       (a) In General.--Section 9003 of the Patient Protection and 
     Affordable Care Act is hereby repealed effective as of the 
     date of the enactment of such Act and any provisions of law 
     amended by such section is amended to read as such provision 
     would read if such section had never been enacted.
       (b) Expansion of Affordability Exception to Individual 
     Mandate.--Section 5000A(e)(1)(A) 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 by striking ``8 percent'' and 
     inserting ``5 percent''.
       (c) Application of Provision.--The amendment made by 
     subsection (b) shall apply as if included in the Patient 
     Protection and Affordable Care Act.
                                 ______
                                 
  SA 3582. Mr. BARRASSO (for himself, Mr. Hatch, and Mr. Coburn) 
proposed an amendment to the bill H.R. 4872, to provide for 
reconciliation pursuant to Title II of the concurrent resolution on the 
budget for fiscal year 2010 (S. Con. Res. 13); as follows:

       At the end of subtitle B of title II, insert the following:

     SEC. 2__. AFFORDABLE PREMIUMS AND COVERAGE.

       The implementation of the Patient Protection and Affordable 
     Care Act (and the amendments made by such Act) shall be 
     conditioned on the Secretary of Health and Human Services 
     certifying to Congress that the implementation of such Act 
     (and amendments) would not increase premiums more than the 
     premium increases projected prior to the date of enactment of 
     such Act.
                                 ______
                                 
  SA 3583. Ms. SNOWE submitted an amendment intended to be proposed by 
her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle A of title I, insert the following:

     SEC. 1006. ELIGIBILITY OF SELF-EMPLOYED FOR TRANSITIONAL 
                   SMALL BUSINESS TAX CREDIT.

       (a) In General.--Section 45R(g) of the Internal Revenue 
     Code of 1986, as added by section 1421 of the Patient 
     Protection and Affordable Care Act, is amended by adding at 
     the end the following:
       ``(4) Credit allowed for self-employed.--
       ``(A) In general.--Notwithstanding subsection (e)(1)(A)(i), 
     the term `employee' shall include an employee withing the 
     meaning of section 401(c)(1).
       ``(B) Payroll taxes.--For purposes of applying subsection 
     (f) to an employee described in subparagraph (A), the term 
     `payroll taxes' includes the amount of taxes imposed on such 
     employee under section 1401(b).''.
       (b) Effective Date.--The amendments made by this section 
     shall take effect as if included in the Patient Protection 
     and Affordable Care Act.
                                 ______
                                 
  SA 3584. Ms. SNOWE submitted an amendment intended to be proposed by 
her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of section 1003, insert the following:
       (e) Preemption of State Laws Extending Employer Mandate to 
     Employers With Fewer Than 50 Employees.--Section 1321(d) of 
     the Patient Protection and Affordable Care Act is amended to 
     read as follows:
       ``(d) No Interference With State Regulatory Authority.--
       ``(1) In general.--Except as provided in paragraph (2), 
     nothing in this title shall be construed to preempt any State 
     law that does not prevent the application of the provisions 
     of this title.
       ``(2) Exception for small employer mandates.--The 
     provisions of, and the amendments made by, this title shall 
     preempt any State law enacted after the date of enactment of 
     this Act that would impose a requirement on any employer with 
     less than 50 full-time employees to, or would impose a 
     penalty on such an employer for failing to, offer health 
     insurance to its employees.''.
                                 ______
                                 
  SA 3585. Ms. SNOWE submitted an amendment intended to be proposed by 
her to the bill H.R. 4872, to provide for reconciliation pursuant to 
Title II of the concurrent resolution on the budget for fiscal year 
2010 (S. Con. Res. 13); which was ordered to lie on the table; as 
follows:

       At the end of subtitle A of title I, insert the following:

     SEC. 1006. EXPANSION OF ENROLLMENT IN CATASTROPHIC PLANS TO 
                   ALL INDIVIDUALS.

       (a) In General.--Section 1302(e) of the Patient Protection 
     and Affordable Care Act is amended to read as follows:
       ``(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 the plan provides--
       ``(A) except as provided in subparagraph (B), the essential 
     health benefits determined under subsection (b), except that 
     the plan provides no benefits for any plan year until

[[Page 4685]]

     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
       ``(B) coverage for at least three primary care visits.
       ``(2) 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.''.
       (b) Eligibility for Enrollment.--Section 1312(d)(3)(C) of 
     such Act is amended to read as follows:
       ``(C) Individuals allowed to enroll in any plan.--A 
     qualified individual may enroll in any qualified health 
     plan.''.
       (c) Eligibility for Subsidies.--Section 36B(c)(3)(A) of the 
     Internal Revenue Code of 1986, as added by section 1401 of 
     such Act, is amended by striking ``, except that such term 
     shall not include a qualified health plan which is a 
     catastrophic health plan described in section 1302(e) of such 
     Act''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect as if included in the Patient Protection 
     and Affordable Care Act.

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